Millcreek of Magee·Magee, Mississippi
The specialist monitors patient service utilization to optimize facility reimbursement and acts as a liaison between managed care organizations and clinical staff. They are responsible for conducting medical necessity reviews, managing the appeal process for denied stays, and providing staff training on documentation requirements.
Proactively monitor utilization of services for patients to optimize reimbursement for the facility.
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. 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. ADDITIONAL REGULATORY REQUIREMENTS: 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. 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.
A high school diploma is required, while degrees in Social Work, Nursing, or Behavioral Health are preferred. Candidates must have clinical experience or two years of experience with the facility's population, and CPR/de-escalation certifications are required.
Market context
In Mississippi, nursing openings commonly signal steady demand in hospitals, clinics, and long-term care settings, especially for candidates who already hold an active state RN license. These roles are competitive because employers often look for graduate-level preparation, recent bedside experience, and readiness to work within facility-specific protocols. Review the AI-summarized requirements and benefits on this platform to save time, then confirm your Mississippi RN license status and highlight your one year of RN experience in your application.