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:

• Associates degree in nursing (LPN or RN) required. Bachelors or Masters 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 experiencein 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.

Required Experience:

IC

Key Skills
Sales Experience,Crane,Customer Service,Communication skills,Heavy Equipment Operation,Microsoft Word,Case Management,OSHA,Team Management,Catheterization,Microsoft Outlook Calendar,EHS
Employment Type : Full-Time
Experience: years
Vacancy: 1
Monthly Salary Salary: 25 - 37