Utilization Review Specialist
About The Position
Make an Impact at Bayside Marin! Are you passionate about ensuring patients receive the highest quality care while optimizing healthcare resources? Bayside Marin, a premier addiction and mental health treatment center, is seeking a Utilization Review Specialist to join our dedicated team. What You’ll Do Monitor and evaluate patient services to ensure appropriate, cost-effective treatment. Review care plans for compliance with clinical standards and payer requirements. Advocate for quality care while managing utilization to support optimal reimbursement. At Bayside Marin, we do more than treat addiction—we transform lives. Our team is the heart of our program: passionate, skilled, and committed to clinical excellence. Many of our staff bring years of personal recovery experience, creating a culture of empathy and understanding. We tailor every treatment plan to meet the unique needs of each client because we know recovery is personal. What We’re Looking For Strong analytical and communication skills. Experience in utilization review or healthcare reimbursement preferred. A commitment to advocating for quality care and resource management.
Requirements
- High school diploma or equivalent.
- Clinical experience is required, or two or more years' experience working with the facility's population.
- 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.
Nice To Haves
- Associate's, Bachelor's, or M aster’s degree in S ocial W ork , B ehavioral or M ental H ealth, N ursing, or a related health field.
- Previous experience in utilization management is preferred
- 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.
Responsibilities
- 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 extension s and i nform 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.
- Perform other functions and tasks as assigned.
Benefits
- Full benefits package, including health, dental, vision, and more.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
Number of Employees
5,001-10,000 employees
