Utilization Specialist

Park Royal Hospital is a private free-standing 126-bed psychiatric hospital that provides life-changing care for adolescents 12-17 years, adults 18 years, and older and senior adults. Inpatient and outpatient treatment are provided for depression, anxiety, mood disorders, memory problems, post-traumatic stress disorder, and other mental illnesses as well as co-occurring substance abuse disorders ​PURPOSE STATEMENT: ​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