Utilization Specialist

7 days ago


Ada Oklahoma, United States Rolling Hills Hospital Full time
Job Summary

We are seeking a highly skilled Utilization Specialist to join our team at Rolling Hills Hospital. The successful candidate will be responsible for proactively monitoring the utilization of services for patients to optimize reimbursement for the facility.

Key Responsibilities
  • Act as liaison between managed care organizations and the facility's professional clinical staff.
  • Conduct reviews of insurance plans or other managed care organizations (MCOs) and coordinate the flow of communication concerning reimbursement requirements.
  • Monitor patient length of stay and extensions and inform clinical and medical staff on issues that may impact length of stay.
  • 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.
  • Conduct quality reviews for medical necessity and services provided.
  • Facilitate peer review calls between facility and external organizations.
  • Initiate and complete the formal appeal process for denied admissions or continued stay.
  • Assist the admissions department with pre-certifications of care.
  • Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria and medical necessity updates.
Qualifications
  • High school diploma or equivalent.
  • Associate's, Bachelor's, or Master's degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field (preferred).
  • Clinical experience is required, or two or more years' experience working with the facility's population.
  • Previous experience in utilization management is preferred.
  • Preferred licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I within the state where the facility provides services.
  • CPR and de-escalation and restraint certification required.


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