Utilization Review Specialist

2 weeks ago


Conway, Arkansas, United States Acadia Healthcare Full time
Purpose and Scope

The Utilization Review Specialist plays a critical role in optimizing reimbursement for the facility while ensuring quality of services provided and medical necessity. This position serves as a liaison between managed care organizations and the facility's professional clinical staff.

Key Responsibilities
  • Conduct reviews in accordance with certification requirements of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.
  • Inform clinical and medical staff of any specific concerns that would extend or restrict the length of stay of patients.
  • Keep accurate records of all contact with external organizations and persons who have legitimate interest and legal access to information on the care of patients.
  • Facilitate peer review calls between facility and external organizations.
  • Act in coordination with the leadership team of the facility or corporate office to improve the quality of services provided within the organization.
  • Assist the admissions department with pre-certifications of care.
  • Initiate and complete the formal appeal process for denied admissions or continued stay.
  • Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.
  • Gather and develop statistical and narrative information to report on utilization, non-certified days (including identified causes and appeal information), discharges and quality of services, as required by the facility leadership or corporate office.
Requirements
  • Licensed LPN or RN, or Associate's Degree, Bachelor's Degree in Social Work, behavioral or mental health, nursing or other related health field; Master's degree in social work, counseling, nursing or related health field preferred.
  • 2+ years' experience with the population of the facility and previous experience in utilization management preferred.
  • Current licensure as an LPN or RN within the state where the facility provides services; or current clinical professional license or certification, as required, within the state where the facility provides services.


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