Geisinger Behavioral Health Center Danville·Danville, Pennsylvania
The specialist monitors service utilization to optimize facility reimbursement and acts as a liaison between managed care organizations and clinical staff. Key duties include conducting medical necessity reviews, managing the appeal process for denied stays, and providing staff training on documentation requirements.
Overview Utilization Specialist – Geisinger Behavioral Health Center Danville Join our team as a Utilization Specialist and help ensure patients receive the care they need while supporting effective coordination with insurance providers! In this role, you'll work closely with clinical teams and managed care organizations to manage authorizations, reviews, appeals, and reimbursement processes, making a meaningful impact on both patient outcomes and organizational success.
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. GBDAN
A high school diploma is required, while degrees in Social Work, Nursing, or Behavioral Health are preferred. Candidates must have clinical experience or at least two years of experience with the facility's patient population.
Market context
Behavioral health employers in Pennsylvania often seek candidates with direct patient care experience, and roles can be more competitive when applicants also bring phlebotomy certification or experience in crisis, detox, or acute psychiatric settings. This posting requires a high school diploma or GED plus at least one year of patient care experience, and the listed requirements and benefits are AI-summarized from the original job description to save you research time. If you’re considering applying, review whether your experience matches the setting and be ready to highlight any behavioral-health or phlebotomy background.
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