Utilization Specialist

Utilization Specialist

On-site Madison, WI

Full time

Why Join

• Competitive compensation with industry leading annual performance-based bonus opportunity
• Comprehensive benefits including medical, dental, and vision insurance
• 401(k) with company match to support your financial future
• Generous paid time off for vacation, sick days, and holidays
• Professional development & leadership training to sharpen your skills

Purpose Statement

Proactively monitor utilization of services for patients to optimize reimbursement for the facility

Essential Functions

• Act 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 Functions

• Perform other functions and tasks as assigned.

Education/Experience/Skill Requirements

• Required 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 preferred

Licenses/Designations/Certifications

• Preferred 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.