Utilization Review Specialist

About the position

The Utilization Review Specialist serves as a critical liaison between managed care organizations and the clinical staff at RiverWoods Behavioral Health. This role involves conducting reviews of insurance plans, monitoring patient length of stay, and ensuring compliance with medical necessity and quality standards. The specialist will also facilitate communication regarding reimbursement requirements and assist with the pre-certification of care, while providing ongoing support and training to staff.

Responsibilities
• Act as liaison between managed care organizations and facility professional clinical staff.
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• Conduct reviews of insurance plans or other managed care organizations (MCOs) according to certification requirements.
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• Monitor patient length of stay and extensions, informing clinical and medical staff on related issues.
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• Gather and develop statistical and narrative information for reporting on utilization, non-certified days, discharges, and quality of services.
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• Conduct quality reviews for medical necessity and services provided.
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• Facilitate peer review calls between facility and external organizations.
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• Initiate and complete the formal appeal process for denied admissions or continued stay.
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• Assist the admissions department with pre-certifications of care.
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• Provide ongoing support and training for staff on documentation or charting requirements, continued stay criteria, and medical necessity updates.

Requirements
• Associate's degree in nursing (LPN or RN) required.
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• Bachelor's or Master's degree in social work, behavioral or mental health, nursing, or other related health field preferred.
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• Two or more years' experience with the population of the facility and previous experience in utilization management preferred.
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• Current licensure as an LPN or RN within the state where the facility provides services; or current clinical professional license or certification as required.
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• CPR and de-escalation and restraint certification required (training available upon hire).
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• First aid may be required based on state or facility requirements.

Nice-to-haves

Benefits

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