Utilization Review Specialist, Behavioral Health

Sutter Health; Berkeley (CA); On-site; USD 67,000 - 101,000; Full time

Job summary

Sutter Health, at ABMS C-Alta Bates Herrick Campus in Berkeley, CA, seeks a utilization management professional to justify admissions and manage continued stay decisions. You will develop and monitor systems for appeal/denial processes, coordinate care utilization, and liaise with payers and hospital departments to ensure optimal service and reimbursement.

The role requires a Master’s in Social Work or related field, strong data interpretation, and proficiency with clinical/administrative

Qualifications

• Master's in Social Work or related field is required.
• Working knowledge of medical terminology and current treatments.
• Ability to interpret data and instructions from various sources.
• Strong written and verbal communication skills with teammates and hospital staff.
• Good time management and ability to prioritize within policies.
• Proficient in computer applications including Crystal Reports, Midas Plus, Excel, Sunrise, MS Word, PCIS, InterQual.
• Ability to work independently and as part of a team while handling multiple tasks.
• Protect the privacy of patients' PHI.
• Build collaborative relationships to meet departmental and corporate objectives.

Responsibilities

• Accumulates, interprets, and documents information to justify hospital admission and continuation of care.
• Coordinates utilization management activities and tracks data trends.
• Acts as liaison between payers, business office, admissions staff, and review organizations.
• Ensures documentation meets privacy and safety standards while delivering quality care.

Skills

Medical terminology

Data interpretation

Communication skills

Time management

Team collaboration

PHI privacy

Problem solving

Education

Master's in Social Work

Tools

Crystal Reports

Midas Plus

Excel

Sunrise

MS Word

PCIS

InterQual

Job description

We are so glad you are interested in joining Sutter Health!

Organization

ABSMC-Alta Bates Herrick Campus

Position Overview

Accumulates, interprets, and documents timely information to justify acute hospital admission, need for continued stay, and proper utilization of physician, nursing, and ancillary services. Responsible for concurrent review on specific patients. Develops, coordinates and monitors systems for the appeal/denial process, tracks and trends data, and coordinates utilization management activities for the assigned area. Collaborates with hospital administration, medical staff, patient registration and representatives of review organizations and others to ensure effective utilization of services and appropriate service reimbursement. Monitors and acts as a liaison between external payers, internal business office, admissions staff, and clerical unit staff to assure that quality care is delivered at the appropriate level of service and that documentation of care meets appropriate standards. Interfaces with hospital administration and unit medical doctors and provides data related to the current management of resources. Adheres to all local/state/federal regulations, codes, policies and procedures to ensure privacy and safety while delivering optimal patient care.

DEPARTMENT REQUIRED EDUCATION

• Department, Behavioral Health: Master's in Social Work or related field

Skills And Knowledge

• Working knowledge of medical terminology, including general knowledge of illnesses, current treatments and their physical and psychosocial sequelae
• Knowledge of alternate levels of care including criteria required for payment and applications processes
• Ability to interpret a variety of data and instructions, furnished in written, oral, diagram, or schedule form
• Possess written and verbal communications skills to communicate with fellow team members, supervisors, patients, and other hospital personnel
• Well-developed time management and organizational skills, including the ability to prioritize assignments and work within standardized policies and procedures to achieve objectives and meet deadlines
• Demonstrated knowledge of computer applications, such as Crystal Report writing, Midas Plus, Excel, Sunrise, MS Word, PCIS, and InterQual
• Work independently, as well as be part of the team, including accomplishing multiple tasks in an environment with interruptions
• Identify, evaluate and resolve standard problems by selecting appropriate solutions from established options
• Ensure the privacy of each patient’s protected health information (PHI)
• Build collaborates relationships with peers and other staff members to achieve departmental and corporate objectives

Job Shift

Days

Schedule

Full Time

Shift Hours

8

Days Of The Week

Monday - Friday

Weekend Requirements

None

Benefits

Yes

Unions

No

Position Status

Non-Exempt

Weekly Hours

40

Employee Status

Regular

Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

Pay Range is $48.78 to $73.17 / hour

The posted pay range is based on the position's primary work location. Candidates who reside and work outside of that location may be subject to a different pay range based on their work location. Candidate starting salaries consider multiple factors, including, but not limited to a candidate's experience, education, skills, licensure, certifications, departmental equity, training, and organizational needs. Base pay is only one component of Sutter Health's comprehensive total rewards program. Eligible positions also include a comprehensive benefits package.