Utilization Review Specialist — Onsite (Behavioral Health)

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

Job summary

San Jose Behavioral Health seeks a Utilization Review Specialist (Full Time) to support the Utilization Department in an acute psychiatric hospital. Responsibilities include concurrent reviews, pre-certifications, discharge planning, and providing guidance on documentation and medical necessity.

The role serves as liaison with managed care organizations, monitors length of stay, and reports utilization data, contributing to quality of care and compliance across the clinical team.

Qualifications

• Associate Degree in Nursing (LPN/LVN/RN) is required.
• Two or more years' experience with the facility's population preferred.
• Experience in utilization management preferred.

Responsibilities

• Act as liaison between managed care organizations and facility clinical staff.
• Conduct reviews of insurance plans and coordinate communication on reimbursement requirements.
• Monitor patient length of stay and inform staff of related issues.
• Gather data to report on utilization, discharges, and quality of services.
• Perform quality reviews for medical necessity and services provided.
• Initiate and complete the formal appeal process for denied admissions or continued stay.
• Assist admissions with pre-certifications of care.
• Provide training for staff on documentation and criteria updates.

Skills

Utilization management

Pre-certification & reviews

Liaison with MCOs

CPR & de-escalation training

Education

Associate Degree in Nursing (LPN/LVN/RN) Required.

Bachelor/Master in Social Work, Behavioral Health, Nursing or related field preferred.

Job description

San Jose Behavioral Health seeks a Utilization Review Specialist (Full Time) to support the Utilization Department in an acute psychiatric hospital. Responsibilities include concurrent reviews, pre-certifications, discharge planning, and providing guidance on documentation and medical necessity.

The role serves as liaison with managed care organizations, monitors length of stay, and reports utilization data, contributing to quality of care and compliance across the clinical team.