Utilization Specialist - Full Time

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 is currently seeking a Utilization Review Specialist - Full Time to assist the Utilization Department staff with comprehensive inpatient care and treatment within our 133-bed Acute Psychiatric Hospital.

San Jose Behavioral Health is where adults and adolescents can receive comprehensive inpatient treatment for a range of behavioral and mental health disorders. Conveniently located in the heart of San Jose the hospital is easily accessible to residents in Santa Clara County, San Mateo County, and Alameda County.

Purpose Statement

The Utilization Review Specialist coordinates and assesses the inpatient census for appropriate alternate health care service needs. Responsibilities include performing on-site and/or telephonic concurrent review of acute and sub-acute services, as well as pre-certification review for all services following the plans authorization guidelines. Also, coordinate with appropriate discharge planning processes, providing feedback on documentation processes; and functions as a resource to the clinical team regarding approved criteria, practice guidelines and alternative treatment options.

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

• Associate Degree in Nursing(LPN/LVN/RN) Required.
• Bachelors or Masters degree in Social Work, Behavioral Health Or Mental Health, Nursing or Other related health field preferred.
• Two or more year's experience with the population of the facility preferred.
• Previous experience in utilization management is preferred

Licenses/Designations/Certifications

• LMFT, LMSW, LCSW, LPC, LPC-I 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.

Additional Regulatory Requirements

While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances

(e.g. emergencies, changes in workload, rush jobs or technological developments) dictate.

We are committed to providing equal employment opportunities to all applicants for employment regardless of an individual’s characteristics protected by applicable state, federal and local laws.

Compensation

Compensation for roles at San Jose Behavioral Health varies depending on a wide array of factors including but not limited to the specific location, role, skill set, and level of experience.As required by local law, San Jose Behavioral Health provides a reasonable hourly range of compensation for roles that may be hired in California as set forth below.

Salary Range: LMFT/LPCC/LCSW $33.00 - $50.00 per hour - Based on Experience

Salary Range: LVN $33.00 - $43.75 per hour - Based on Experience

Salary Range: RN: $60.00 - per hour - Based on Experience

Location: ONSITE ONLY

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities.

SANJO