Utilization Specialist

Utilization SpecialistOn-site Madison, WIFull timeWhy JoinCompetitive compensation with industry leading annual performance-based bonus opportunityComprehensive benefits including medical, dental, and vision insurance401(k) with company match to support your financial futureGenerous paid time off for vacation, sick days, and holidaysProfessional development & leadership training to sharpen your skillsPurpose StatementProactively monitor utilization of services for patients to optimize reimbursement for the facilityEssential FunctionsAct as liaison between managed care organizations and the facility professional clinical staff.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.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.Other FunctionsPerform other functions and tasks as assigned.Education/Experience/Skill RequirementsRequired Education: High school diploma or equivalent.Preferred Education: Associate's, Bachelor's, or Master's degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field.Experience: Clinical experience is required, or two or more years' experience working with the facility's population. Previous experience in utilization management is preferredLicenses/Designations/CertificationsPreferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I 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.CPR and de-escalation and restraint certification required (training available upon hire and offered by facility.First aid may be required based on state or facility requirements.