Utilization Specialist

5 days ago


Nashville, Tennessee, United States Ascension St. Thomas Behavioral Health Hospital Full time
Job Summary

Ascension St. Thomas Behavioral Health Hospital is seeking a skilled Utilization Specialist to join our team. As a Utilization Specialist, you will play a critical role in optimizing reimbursement for our facility and ensuring the highest quality of care for our patients.

Key Responsibilities
  • Monitor patient length of stay and extensions, and inform clinical and medical staff on issues that may impact length of stay.
  • Conduct reviews of insurance plans and coordinate communication with managed care organizations to ensure reimbursement requirements are met.
  • Gather and develop statistical and narrative information to report on utilization, non-certified days, discharges, and quality of services.
  • 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.
Requirements
  • High school diploma or equivalent required; Associate's, Bachelor's, or Master's degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field preferred.
  • Clinical experience required; two or more years' experience working with the facility's population preferred.
  • Previous experience in utilization management highly preferred.
  • LPN, RN, LMSW, LCSW, LPC, LPC-I licensure or current clinical professional license or certification required within the state where the facility provides services.
  • CPR and de-escalation and restraint certification required; first aid may be required based on state or facility requirements.


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