Utilization Specialist

MSW Or Asn Rn

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

About Us: As one of the leading inpatient treatment programs in South Carolina, Rebound Behavioral Health Hospital offers short-term, recovery-oriented treatment for mental health disorders, substance abuse, and co-occurring concerns. Our approach is designed to rapidly identify treatment strategies for all who come to us that promote recovery and provide the stabilization necessary to help our clients return to their community as happy, productive members. Our inpatient program provides an interdisciplinary staff who serve as experts and work alongside our clients to assist each person who comes to us to identify and reach treatment goals. As our treatment program is largely group-focused, clients can draw from input from staff, peers, and the treatment milieu as they regain stability and prepare to return to their home environment. Our treatment professionals include:

• Licensed social workers
• Substance abuse counselors
• Board-certified psychiatrists
• Recreational and expressive therapists
• Psychiatric and substance abuse nurses
• Behavioral health technicians

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.