Utilization Review Specialist - Full TimeSan Jose Behavioral Health is currently seeking a Utilization Review Specialist - Full Time to assist the Utilization Department staff with comprehensive inpatient care and treatment within our 133-bed Acute Psychiatric Hospital. San Jose Behavioral Health is where adults and adolescents can receive comprehensive inpatient treatment for a range of behavioral and mental health disorders. Conveniently located in the heart of San Jose the hospital is easily accessible to residents in Santa Clara County, San Mateo County, and Alameda County.
Salary Range: $33.00 - $50.00 per hour - Based on Experience
Location: ONSITE ONLYPurpose Statement
The Utilization Review Specialist coordinates and assesses the inpatient census for appropriate alternate health care service needs. Responsibilities include performing on-site and/or telephonic concurrent review of acute and sub-acute services, as well as pre-certification review for all services following the plans authorization guidelines. Also, coordinate with appropriate discharge planning processes, providing feedback on documentation processes; and functions as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options.
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:
- Associate Degree in Nursing (LPN/LVN/RN) Required.
- Bachelors or Masters degree in Social Work, Behavioral Health Or Mental Health, Nursing or Other related health field preferred.
- Two or more year's experience with the population of the facility preferred.
- Previous experience in utilization management is preferred
Licenses/Designations/Certifications:
LMFT, 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).
Additional Regulatory Requirements: N/A
