Utilization Review Specialist, Behavioral Health

Sutter Health•Berkeley, CA

About The Position

The Utilization Review Specialist, Behavioral Health accumulates, interprets, and documents timely information to justify acute hospital admission, continued stay, and appropriate use of physician, nursing, and ancillary services. The role conducts concurrent reviews for assigned patients and develops, coordinates, and monitors systems for appeals and denials, including tracking and trending data and coordinating utilization management activities for the assigned area. The specialist collaborates with hospital administration, medical staff, patient registration, review organization representatives, and others to support effective utilization of services and appropriate reimbursement. The role acts as a liaison among external payers, the internal business office, admissions staff, and clerical unit staff to help ensure quality care is delivered at the appropriate service level and care documentation meets applicable standards. The specialist interfaces with hospital administration and unit physicians and provides data related to resource management. The position follows applicable local, state, and federal regulations, codes, policies, and procedures to protect privacy and safety while supporting optimal patient care.

Requirements

Master’s degree in Social Work or a related field.
Working knowledge of medical terminology, illnesses, current treatments, and their physical and psychosocial sequelae.
Knowledge of alternate levels of care, including payment criteria and application processes.
Ability to interpret data and instructions presented in written, oral, diagram, or schedule form.
Written and verbal communication skills for communicating with team members, supervisors, patients, and other hospital personnel.
Well-developed time management and organizational skills, including the ability to prioritize assignments and meet deadlines within standardized policies and procedures.
Demonstrated knowledge of computer applications, including Crystal Report writing, Midas Plus, Excel, Sunrise, MS Word, PCIS, and InterQual.
Ability to work independently and as part of a team, including managing multiple tasks in an environment with interruptions.
Ability to identify, evaluate, and resolve standard problems by selecting appropriate solutions from established options.
Ability to protect the privacy of patients’ protected health information.
Ability to build collaborative relationships with peers and other staff members to achieve departmental and corporate objectives.

Responsibilities

Accumulate, interpret, and document information to justify acute hospital admission, continued stay, and appropriate utilization of physician, nursing, and ancillary services.
Conduct concurrent reviews for assigned patients.
Develop, coordinate, and monitor appeal and denial processes.
Track and trend data and coordinate utilization management activities for the assigned area.
Collaborate with hospital administration, medical staff, patient registration, review organization representatives, and others to support effective service utilization and appropriate reimbursement.
Act as a liaison among external payers, the internal business office, admissions staff, and clerical unit staff.
Help ensure care is delivered at the appropriate service level and documentation meets applicable standards.
Provide hospital administration and unit physicians with data related to current resource management.
Adhere to applicable regulations, codes, policies, and procedures to ensure patient privacy and safety.