Inpatient Utilization Review Specialist

San Jose Behavioral Health Hospital; San Jose (CA); On-site; USD 45,000 - 83,000; Full time

Job summary

San Jose Behavioral Health Hospital in San Jose, CA is seeking a Utilization Review Specialist (full-time) to support the Utilization Department with inpatient care coordination and review for approved services. The role involves concurrent reviews, pre-certifications, discharge planning input, and chart documentation guidance to the clinical team.

The incumbent coordinates with managed care organizations, monitors length of stay, reports on utilization metrics, and facilitates appeals when

Qualifications

• Associate Degree in Nursing (LPN/LVN/RN) required.
• Bachelor's or Master's in Social Work, Behavioral Health or related field preferred.
• Two or more years' experience with the facility population preferred.
• Experience in utilization management preferred.

Responsibilities

• Act as liaison between managed care organizations and facility staff.
• Conduct reviews of insurance plans and communicate reimbursement requirements.
• Monitor patient length of stay and inform staff of issues.
• Gather statistics and narrative data on utilization and discharges.
• Conduct quality reviews for medical necessity and services.
• Facilitate peer review calls with external organizations.
• Initiate and complete formal appeal processes for denials.
• Assist admissions with pre-certifications of care.
• Provide training on documentation and medical necessity updates.
• Perform other functions and tasks as assigned.

Skills

Clinical nursing

Utilization review

Insurance knowledge

Communication

Education

Associate Degree in Nursing (LPN/LVN/RN)

Bachelor's or Master’s in Social Work or Behavioral Health

Job description

San Jose Behavioral Health Hospital in San Jose, CA is seeking a Utilization Review Specialist (full-time) to support the Utilization Department with inpatient care coordination and review for approved services. The role involves concurrent reviews, pre-certifications, discharge planning input, and chart documentation guidance to the clinical team.

The incumbent coordinates with managed care organizations, monitors length of stay, reports on utilization metrics, and facilitates appeals when