Utilization Review Specialist

Acadia Healthcare • Louisville, TN

382d

About The Position

The Utilization Review Specialist plays a critical role in managing the communication between managed care organizations and the clinical staff at the facility. This position is responsible for conducting reviews of insurance plans, monitoring patient stays, and ensuring compliance with medical necessity standards. The specialist will also facilitate peer reviews and assist with the appeal process for denied admissions, providing essential support and training to staff regarding documentation and medical necessity updates.

Requirements

• Associate's degree in nursing (LPN or RN) required; Bachelor's or Master's degree in social work, behavioral or mental health, nursing, or related health field preferred.
• Two or more years' experience with the population of the facility and previous experience in utilization management preferred.

Responsibilities

• Act as liaison between managed care organizations and the facility professional clinical staff.
• Conduct reviews of insurance plans or other managed care organizations (MCOs) according to certification requirements.
• Monitor patient length of stay and extensions, informing clinical and medical staff on related issues.
• Gather and develop statistical and narrative information for reporting on utilization, non-certified days, discharges, and quality of services.
• 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.

What This Job Offers

• Job Type: Full-time
• Industry: Hospitals
• Education Level: Associate degree