Utilization Specialist

Overview

San Jose Behavioral Health is currently seeking an experienced Utilization Review Specialist Full Time to join our growing team. 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. The Utilization Review Specialist will 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.

San Jose Behavioral Health is a 133 bed inpatient mental health facility in Northern California. Stop by and meet our an amazing leadership team, who are engaged with our staff and our patients recovery. Growth opportunities are available and encouraged! Join a team of like-minded individuals who believe in providing compassionate and quality care. We offer employee recognition and incentive events to promote safety, healthy habits, and recognize commitment and hard work from our staff.

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. The Hospital campus is situated amid gently rolling hills and features serene views of beautiful natural surroundings.

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:

• Associate's degree in nursing (LPN or RN) required. Bachelor's or Master's degree in social work, behavioral or mental health, nursing or other related health field preferred.

• Two or more years' experience with the population of the facility and previous experience in utilization management preferred.

LICENSES/DESIGNATIONS/CERTIFICATIONS:

• Current licensure as an LPN or RN 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.

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.

SJBH Range = $38/hour - $44.28/hour - DOE

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.

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