San Jose Behavioral Health
Utilization Specialist - Full Time
San Jose Behavioral Health, San Jose, California, United States, 95199
Utilization Review Specialist – Full Time
Salary Range:
$33.00 – $44.00 per hour – Based On Experience Location:
ONSITE ONLY – San Jose, CA
San Jose Behavioral Health
is a 133-bed Acute Psychiatric Hospital located in the heart of San Jose. We provide comprehensive inpatient treatment for adults and adolescents with a range of behavioral and mental health disorders. Our hospital is easily accessible to residents in Santa Clara County, San Mateo County and Alameda County.
Benefits • Competitive salary • Medical, dental and vision insurance • 401(k) plan with match • Paid time off – vacation, sick, personal days and extended sick leave plus holidays/holiday pay • Excellent training program • Professional growth opportunities with a national family of hospitals and facilities
Purpose 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 plan authorization guidelines. The specialist also coordinates with discharge planning processes, provides 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 managed care organizations (MCOs) and coordinate 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 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.
Bachelor’s or Master’s degree in Social Work, Behavioral Health or Mental Health, Nursing or related health field – Preferred.
Two or more years’ experience with the population of the facility – Preferred.
Previous experience in utilization management – 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).
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.
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$33.00 – $44.00 per hour – Based On Experience Location:
ONSITE ONLY – San Jose, CA
San Jose Behavioral Health
is a 133-bed Acute Psychiatric Hospital located in the heart of San Jose. We provide comprehensive inpatient treatment for adults and adolescents with a range of behavioral and mental health disorders. Our hospital is easily accessible to residents in Santa Clara County, San Mateo County and Alameda County.
Benefits • Competitive salary • Medical, dental and vision insurance • 401(k) plan with match • Paid time off – vacation, sick, personal days and extended sick leave plus holidays/holiday pay • Excellent training program • Professional growth opportunities with a national family of hospitals and facilities
Purpose 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 plan authorization guidelines. The specialist also coordinates with discharge planning processes, provides 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 managed care organizations (MCOs) and coordinate 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 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.
Bachelor’s or Master’s degree in Social Work, Behavioral Health or Mental Health, Nursing or related health field – Preferred.
Two or more years’ experience with the population of the facility – Preferred.
Previous experience in utilization management – 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).
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.
#J-18808-Ljbffr