Utilization Specialist Full-time
Acadia•Riverside, CA
•Onsite
About The Position
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!
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 Master’s degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field.
- Previous experience in utilization management is preferred.
- 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.
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 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.
- Perform other functions and tasks as assigned.
Benefits
- Competitive Salary
- Paid Time Off
- Paid Holidays (8 Total)
- Medical, Dental, & Vision Insurance
- FSA & HSA Plans
- Long-Term & Short-Term Disability
- Company Paid Life Insurance
- Supplemental Life Insurance
- Employee Assistance Program
- Employee Discount Program
- 401(k) Retirement Plan with Company Match
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
