Utilization & Reimbursement Specialist

Harboroaks; Riverside (CA); On-site; USD 43,000 - 69,000; Full time

Job summary

Pacific Grove Hospital in Riverside, CA is seeking a PRN utilization management professional to optimize reimbursement and coordinate care with managed care organizations. The role focuses on reviews, data gathering, and ensuring medical necessity.

Responsibilities include monitoring length of stay, reporting utilization metrics, and supporting staff on documentation, pre-certifications, and appeal processes. Strong clinical background and CPR certification are preferred.

Qualifications

• Required Education: High school diploma or equivalent.
• Preferred Education: Associate's, Bachelor's, or Master's degree in Social Work, Behavioral or Mental Health, Nursing, or related health field.
• Experience: Clinical experience is required, or two or more years' experience working with the facility's population. Previous experience in utilization management is preferred.
• Licenses/Designations/Certifications: Preferred Licensure includes LPN, RN, LMSW, LCSW, LPC, or LPC-I; CPR and de-escalation and restraint certification required.

Responsibilities

• Act as liaison between managed care organizations and the facility professional clinical staff.
• Conduct reviews of insurance plans or other managed care organizations and coordinate communication concerning reimbursement requirements.
• Monitor patient length of stay 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, discharges and quality of services.
• 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 requirements and continued stay criteria.

Education

Associate's, Bachelor's, or Master's degree in Social Work, Behavioral or Mental Health, Nursing, or related health field

Job description

Pacific Grove Hospital in Riverside, CA is seeking a PRN utilization management professional to optimize reimbursement and coordinate care with managed care organizations. The role focuses on reviews, data gathering, and ensuring medical necessity.

Responsibilities include monitoring length of stay, reporting utilization metrics, and supporting staff on documentation, pre-certifications, and appeal processes. Strong clinical background and CPR certification are preferred.