High school diploma or equivalent required; higher education preferred (Associate's, Bachelor's, or Master's in relevant fields).
Clinical experience required; two or more years working with the facility's population preferred.
Previous experience in utilization management is a plus.
Preferred licensure includes LPN, RN, LMSW, LCSW, LPC, or LPC-I in the relevant state.
CPR and de-escalation and restraint certification required (training provided).
Responsibilities
Act as a liaison between managed care organizations and clinical staff.
Conduct insurance reviews and coordinate communication on reimbursement requirements.
Monitor patient length of stay and inform staff on related issues.
Gather statistical and narrative data for reporting on utilization and quality of services.
Conduct quality reviews for medical necessity and services provided.
Facilitate peer review calls with external organizations.
Initiate and complete appeals for denied admissions or continued stays.
Assist admissions with pre-certifications of care.
Provide ongoing training for staff on documentation and medical necessity updates.
Benefits
Training provided for CPR and de-escalation and restraint certification.
Opportunities for professional development and continuing education.
Full Job Description
Overview
The Utilization Specialist proactively monitors utilization of services for patients to optimize reimbursement for the facility.
Pay Range: $39.02 to $46.59/hr.
Responsibilities
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.
Qualifications
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.
Pay Range: $39.02 to $46.59/hr.
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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About Valley Behavioral Health
Valley Behavioral Health is a non-profit organization that provides mental health and substance abuse treatment services to individuals and families in Utah. The organization was founded in 1989 and has since grown to become one of the largest providers of behavioral health services in the state. Valley Behavioral Health offers a wide range of services, including outpatient therapy, medication management, crisis intervention, and residential treatment. The organization is committed to providing high-quality, evidence-based care to its clients and to promoting mental health awareness and education in the community.
