Utilization Specialist

2 weeks ago

Harlingen, Texas, United States Summit BHC Full time
About the Job:

The Utilization Specialist is responsible for reviewing assigned admissions, continued stays, utilization practices, and discharge planning according to approved clinically valid criteria. This role requires effective communication with insurance companies, health maintenance organizations (HMOs), and other similar entities to obtain authorizations and complete other pertinent processes. The Utilization Specialist will also educate hospital staff about requirements and trends.

Roles and Responsibilities:
  • Perform admission, concurrent, continued stay, and retrospective reviews using established hospital criteria.
  • Communicate effectively with insurance companies, HMOs, and other similar entities for approval of initial or additional inpatient days for treatment.
  • Communicate directly with physicians and other providers regarding specific inquiries and perceived trends of issues as they relate to utilization management.
  • Appeal all denials ensuring accuracy of information and effective coordination of correspondence.
  • Assist the admissions department with pre-certifications of care.
  • Maintain accurate documentation and files as it relates to utilization management.
  • Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria, and medical necessity updates.
  • Coordinate information and findings with the business office to help recognize or resolve possible payment problems.
  • Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.
  • Investigate short-term length of stays and endeavor to create alternate financial planning which would offer the patient extended days of treatment.
  • Participate in discharge planning as required.
  • 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.
  • Conduct quality reviews for medical necessity and services provided.
  • Facilitate peer review calls between facility and external organizations.
  • Identify potential review problems and discuss them with multi-disciplinary team and/or administration.
  • Act as liaison between managed care organizations and the facility professional clinical staff.
  • Assist with any problems encountered during on-site or telephone reviews by the third-party payers or review organization, when necessary.
Requirements:
  • Graduation from an approved/accredited school of nursing or a Bachelor's degree in social work, behavioral or mental health, or other related health field required.
  • Two or more years of direct clinical experience in a psychiatric or mental health setting required.
  • Current licensure as an LPN or RN or current clinical professional license or certification, as required, within the state where the facility provides services.
Why Palms Behavioral Health?

Palms Behavioral Health offers a comprehensive benefit plan and a competitive salary commensurate with experience and qualifications. Qualified candidates should apply by submitting a resume. Palms Behavioral Health is an EOE. Veterans and military spouses are highly encouraged to apply. Summit BHC is dedicated to serving Veterans with specialized programming at our treatment centers across the country. We recognize and value the unique strengths of the military community in supporting our mission to serve those who have served.

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