Utilization Specialist - PART TIME WEEKENDS (on-site)
Cross Creek Hospital Together with Ascension Seton · Austin, TX, US
5 days agoImpress employers and recruiters.
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About the Role
Proactively monitor utilization of services for patients to optimize reimbursement for the facility.
Responsibilities
- 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.
- Perform other functions and tasks as assigned.
Requirements
- High school diploma or equivalent required.
- Clinical experience is required.
- Two or more years' experience working with the facility's population.
- 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.
Skills
- Previous experience in utilization management is preferred.
Education Level
- Associate's, Bachelor's, or Master’s degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field preferred.
- Preferred Licensure: LVN/LPN, RN, LMSW, LCSW, LPC, LPC-A 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.
Equal Opportunity
- 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.