Utilization Specialist

Join our team at TrustPoint Hospital as a Full Time Utilization Specialist! We are seeking passionate professionals that are dedicated to behavioral health. If you are looking for unparalleled growth opportunities and are wanting to make a meaningful impact in your community, this is the position for you! Hours: Mon-Fri 8am-5pm TrustPoint Hospital is a 217-bed, state-of-the-art treatment center providing comprehensive medical and psychiatric services on both inpatient and outpatient bases. We deliver exceptional care to patients needing acute physical medicine and rehabilitation, adult, adolescent, geriatric psychiatry, and medical psychiatry. TrustPoint Hospital offers an extensive array of benefits to our valued team members. Current offerings encompass: Medical, Dental, and Vision Insurance coverage Health Savings Account (HSA) and Flexible Spending Account (FSA) options Company-paid Basic Life & AD&D insurance Disability benefits 401(k) Retirement Plan with a company match Employee Assistance Program (EAP) and Employee Discount Program Paid Holidays for work-life balance Paid Time Off (PTO) Tuition Reimbursement opportunities for career advancement 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. Additional Regulatory Requirements We are committed to providing equal employment opportunities to all applicants for employment regardless of an individual’s characteristics protected by applicable state, federal and local laws. While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances (e.g. emergencies, changes in workload, rush jobs or technological developments) dictate.

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