Utilization Review Specialist

We offer a full of benefits ranging from:

• Competitive Salary


• Paid Time Off


• Paid Holidays (8 Total)


• Medical, Dental, & Vision Insurance


• FSA & HSA Plans


• Long-Term & Short-Term Disability


• Company Paid Life Insurance


• Supplemental Life Insurance


• Employee Assistance Program


• Employee Discount Program


• 401(k) Retirement Plan with Company Match

Hourly Range: $25.00 – $37.47

Pacific Grove Hospital, is a nationally recognized 68 bed acute psychiatric and chemical dependency treatment center offering inpatient & outpatient services for psychiatric illnesses, addictions & co-occurring disorders. Our hospital offers comprehensive training, dynamic leadership, and personalized support so you can achieve your greatest potential.

Utilization Review Specialist include

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's degree in nursing (LPN or RN) required. Bachelor's or Master’s degree in social work, behavioral or mental health, nursing or other related health field preferred.


• Two or more years' experience with the population of the facility and previous experience in utilization management preferred.

LICENSES/DESIGNATIONS/CERTIFICATIONS:

• Current licensure as an LPN or RN 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.