Utilization Specialist

Job Type Full-Time Position Summary The Utilization Specialist uses strong independent judgment to ensure access to medically necessary, high-quality behavioral health and community-based services across the agency. The Utilization Specialist ensures services align with medical necessity, reimbursement requirements, and regulatory standards, while supporting continuity of care, reducing denials, and promoting operational sustainability while maintaining a client-centered focus. Job Duties Serve as a liaison between managed care organizations (MCOs), payers, and internal clinical and operational teams to support authorization, utilization management, and reimbursement processes. Conduct utilization reviews to ensure services meet medical necessity criteria, payer requirements, and continued stay expectations. Monitor authorizations, service units, length of stay, and extensions; proactively communicate issues that may impact service delivery or reimbursement. Coordinate pre-certifications and authorization requirements prior to service initiation in collaboration with admissions and intake staff. Initiate and manage appeals for denied services or continued stay determinations, including facilitating peer-to-peer reviews as needed. Review clinical documentation within the electronic health record to ensure accuracy, timeliness, and alignment with authorization and payer requirements. Identify documentation gaps or compliance risks and provide guidance to staff on documentation standards and workflows. Conduct quality and utilization reviews to assess appropriateness of services and compliance with payer and regulatory standards. Monitor and report on non-certified days, denials, and utilization trends, including identifying root causes and opportunities for improvement. Assist with internal, payer, and regulatory audits, including documentation review and response to data requests. Develop and analyze utilization reports and metrics to support operational and clinical decision-making. Provide training and ongoing education to staff on documentation standards, medical necessity, and utilization processes. Serve as a resource for staff questions related to utilization management, documentation, and payer expectations. Perform other duties as assigned to support program operations and organizational needs. Required Skills/Abilities Expertise in utilization management, medical necessity, and managed care processes. Strong written and verbal communication skills, with the ability to collaborate effectively across clinical, operational, and external stakeholders. High attention to detail with strong organizational, analytical, and follow-through skills. Proficiency in electronic health records and data tracking/reporting systems. Able to analyze data, identify trends, and support process improvement efforts. Commitment to confidentiality, ethical practice, and client-centered care. Awareness and sensitivity of our constituents and the populations served by employees. Regular and predictable attendance, and promptness for work. Commitment to uphold the mission, vision, and values of Lutheran Family Services. Support the organization’s objective to be an inclusive and accessible workplace. Position Competencies Process Improvement Relationship Building Analytical Skills Accountability Communication Skills Education and Experience High school diploma or equivalent required; bachelor’s degree in social work, behavioral health, nursing or related healthcare field preferred. Two (2) years’ experience working with populations served by LFS or in a related clinical or behavioral health setting required. Experience in community mental health, CCBHC, or nonprofit human services preferred. Active LPN, RN, MSW, CSW, LPC, or another clinical license in Nebraska preferred. Physical Requirements Prolonged periods of sitting and working on a computer. Hybrid or remote work may be available based on operational needs. Flexible scheduling required during audits, appeal deadlines, or high-volume authorization periods. Company-issued laptop and cell phone. Valid driver’s license, liability auto insurance, and ability to drive a personal vehicle for travel between office locations and/or program sites, as needed. Lutheran Family Services is an equal opportunity employer. We do not discriminate against any employee or applicant for employment on the basis of age, race, religion, color, ethnicity, disability, gender, sexual orientation, gender identity, or national origin. #J-18808-Ljbffr