Utilization Specialist PRN

Harboroaks; Riverside (CA); On-site; USD 42,705 - 68,880; Full time

Benefits offered by this job

Flexible scheduling

Competitive Pay

Employee Assistance Program (EAP)

Job summary

Harboroaks in Riverside, CA, seeks a Utilization Review (UR) Specialist for their inpatient psychiatric facility. You will monitor service utilization, ensure quality reviews, and act as a liaison with managed care organizations. Ideal candidates will have clinical experience and preferred licenses (LPN, RN, LMSW, LCSW, LPC). Benefits include flexible scheduling, competitive pay, and employee assistance programs. Join us in providing high-quality behavioral healthcare.

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 a related health field.
• Experience: Clinical experience is required, or two or more years' experience working with the facility's population.

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 on related issues.
• Gather statistical and narrative information for reporting.
• Conduct quality reviews for medical necessity.
• Facilitate peer review calls.
• Complete formal appeal process for denied admissions.
• Assist admissions department with pre-certifications.
• Provide ongoing support and training for staff.

Job description

Overview

Pacific Grove Hospital in Riverside, CA., is a leader in behavioral healthcare, providing superior healthcare treatment to the people, communities, and military installations we serve. We are a private inpatient 68 bed acute psychiatric facility with out-patient services, dedicated to the treatment of behavioral health and substance abuse services. Come join TEAM PGH as a UR Specialist!

• Flexible scheduling
• Competitive Pay
• Employee Assistance Program (EAP)

Hourly pay range: $31-50 DOE and licensure held

PURPOSE STATEMENT

Proactively monitor utilization of services for patients to optimize reimbursement for the facility.

Responsibilities

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.

Qualifications

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS

• 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 a 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: LPN, RN, 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).
• First aid may be required based on state or facility requirements.

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.