Utilization Review Specialist

2 weeks ago


Riverdale, Georgia, United States Acadia Healthcare Full time
Job Summary

We are seeking a highly skilled Utilization Review Specialist to join our team at Acadia Healthcare. As a key member of our clinical operations team, you will play a critical role in ensuring the efficient and effective delivery of healthcare services to our patients.

Key Responsibilities
  • Act as a liaison between managed care organizations and our facility's professional clinical staff to facilitate communication and coordination of care.
  • Conduct thorough reviews of insurance plans and managed care organizations to ensure compliance with certification requirements and reimbursement guidelines.
  • Monitor patient length of stay and extensions, and provide timely notification to clinical and medical staff on potential issues that may impact length of stay.
  • Gather and analyze statistical and narrative information to report on utilization, non-certified days, discharges, and quality of services, as required by facility leadership or corporate office.
  • Conduct quality reviews to ensure medical necessity and services provided align with established standards and guidelines.
  • Facilitate peer review calls between our facility and external organizations to promote collaboration and knowledge sharing.
  • Initiate and complete the formal appeal process for denied admissions or continued stay, ensuring timely and effective resolution.
  • Assist the admissions department with pre-certifications of care, ensuring seamless coordination and communication.
  • Provide ongoing support and training to staff on documentation and charting requirements, continued stay criteria, and medical necessity, promoting a culture of excellence and compliance.
Requirements
  • Associate's degree in nursing (LPN or RN) required; Bachelor's or Master's degree in social work, behavioral or mental health, nursing, or other related health field preferred.
  • Two or more years' experience with the population of our facility and previous experience in utilization management preferred.
  • Current licensure as an LPN or RN within the state where our facility provides services; or current clinical professional license or certification, as required, within the state where our facility provides services.
  • CPR and de-escalation and restraint certification required; first aid may be required based on state or facility requirements.

We are an equal opportunity employer and welcome applications from diverse candidates. If you are a motivated and detail-oriented professional with a passion for delivering high-quality patient care, we encourage you to apply for this exciting opportunity to join our team at Acadia Healthcare.



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