Utilization Specialist

Full Time Utilization Review Specialist

The Refuge provides premier residential treatment for adults aged 18 and older who are struggling with substance use disorders, behavioral health, trauma, eating disorder and other co-occurring disorders. We are looking to hire a Full Time Utilization Review Specialist to join our team. The UR specialist proactively monitors utilization of services for patients to optimize reimbursement for the facility. This is a Monday-Friday, on-site position working 40 hours per week.

Purpose Statement:

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

Pay for this position starts at $20/hr and based on relevant work experience. Higher starting wages for candidates that meet the preferred education criteria will be discussed.

Preferred education: Associate's, Bachelor's or Master's Degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field.

Required experience: Clinical experience is required, 2 or more years experience working in the behavioral health field. Previous experience in utilization management is strongly preferred.

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:

• 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.

Additional Regulatory Requirements:

Details about additional regulatory requirements are not provided in the job post.