Utilization Management Specialist - Acute Care

Location: Naples, Florida
Company: David Lawrence Centers
Job Type: Full-Time or Part-Time
Schedule: Primarily scheduled during standard business hours; however, this position requires regular weekend coverage, holiday coverage, and flexibility to meet operational needs.

Job Summary

The Utilization Management Specialist supports DLC's Acute Care Program by coordinating insurance authorizations, conducting utilization reviews, and serving as a liaison between clients, treatment teams, insurance providers, and internal departments. This role helps ensure appropriate levels of care, timely reimbursement, regulatory compliance, and positive treatment outcomes through effective utilization management, documentation review, payer communication, and data reporting activities. Responsibilities include monitoring authorization status, supporting appeals, and maintaining compliance with payer, regulatory, and accreditation standards.

Key Responsibilities

• Submit, obtain, and track insurance authorizations and precertification's for Acute Care services.
• Conduct initial utilization reviews and continued stay reviews to support medical necessity and appropriate level-of-care determinations.
• Gather, review, and submit required clinical documentation to insurance payers.
• Monitor authorization approvals, denials, and service extensions; communicate outcomes to treatment teams and appropriate departments.
• Assist with appeal requests and denial management by compiling supporting clinical documentation.
• Coordinate with clinicians regarding medical necessity reviews and level-of-care recommendations.
• Serve as a liaison between insurance providers, treatment teams, Client Financial Services, and Accounts Receivable regarding client insurance matters.
• Ensure timely and accurate documentation of utilization management activities within the electronic health record and payer portals.
• Run utilization, authorization, and quality-related data reports as needed for operational review and special projects.
• Participate in meetings with insurance representatives to review quality measures, utilization trends, and payer requirements.
• Maintain compliance with payer requirements, accreditation standards, federal and state regulations, and organizational policies and procedures.
• Support continuous quality improvement initiatives related to utilization management, reimbursement, and service delivery.

Qualifications

Required

• High school diploma or equivalent and a minimum of one (1) year of experience in utilization review, healthcare authorizations, case management, behavioral health, healthcare administration, medical billing, insurance operations, or a related field.
• Experience working with insurance payers, authorizations, claims, or clinical documentation.
• Strong organizational skills with the ability to manage multiple priorities in a fast-paced environment.
• Accurate and detailed recordkeeping, reporting, and documentation skills.
• Ability to work independently while collaborating effectively with multidisciplinary teams.
• Knowledge of confidentiality requirements, HIPAA regulations, and professional documentation standards.
• Ability to ensure all activities are performed in accordance with organizational policies and procedures.

Preferred

• Bachelor's Degree in Nursing, Social Work, Counseling, Psychology, Healthcare Administration, or a related field.
• Two (2) or more years of utilization review, utilization management, managed care, discharge planning, behavioral health, or healthcare reimbursement experience.
• Knowledge of ASAM Criteria, Medicaid Managed Care, Medicare regulations, and behavioral health documentation requirements.
• Experience utilizing electronic health records (EHRs), payer portals, and healthcare reporting systems.
• Professional licensure or certification in a related healthcare field.

Additional Requirements

• Microsoft Office 365 proficiency, including Teams and video conferencing.
• Remain compliant with all required trainings and immunizations.
• Ability to pass Level II DCF Mental Health Fingerprinting (General Information can be found HERE), Drug Screen and Local Criminal Check. 

Physical Requirements

This position requires a mix of physical activities throughout the workday. Duties involve periods of standing, sitting, and walking, often across various areas of the site. The role also includes tasks that may require bending, reaching, and other physical movements. Candidates must be able to occasionally lift and carry items weighing up to 50 pounds. A reasonable level of physical stamina and mobility is necessary to successfully perform the essential functions of this role.