Utilization Review Specialist
- 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.
- 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
- Preferred Licensure: LPN, RN, LMSW, LCSW, LPC, LPC-I
- 401(k) with matching
- Employee assistance program
- Paid time off
- Professional development assistance
- Tuition reimbursement
Recommended Jobs
Collections Coordinator
A large global professional services firm seeks a Collections Coordinator to join their dynamic team on a temporary basis. Firm is ranked among the Top 3 “Best Firms To Work For” to work for in their…
Field Supervisor
Job Overview The Field Supervisor is responsible for keeping the rig and jobsite operating at maximum efficiency, is accountable for workers safety, manages equipment maintenance and serves as the p…
Remote Neurology Telehealth Licensed Vocational Nurse (LVN) - California License Required
Our client is a venture-backed healthcare organization transforming reactive healthcare into proactive care through technology and continuous engagement. Focused on neurodegenerative diseases, our cli…
Children and Family Services Attorney III
Job Description and Duties This is a re-post. If you previously applied, there is no need to re-apply as your application is on file and will be considered. The California Department of Social …
Director, Finance
Work Schedule Standard (Mon-Fri) Environmental Conditions Office Department Finance / Corporate FP&A (TDX Division) Reports to: Sr Director Finance (Division CFO), TDX Division …
Restaurant Host
Description Comal has been a community mainstay since opening in downtown Berkeley in 2012. Recognized for its excellence by Michelin Bib Gourmand & SF Chronicle Top 100, Comal serves delicious re…
LOCUM Cardiothoracic Physician Assistant
We are staffing up a full time locum Cardiothoracic Surgery Physician Assistant or Nurse Practitioner near Fruitvale, CO In this 24-hour 'on call' role the candidate will be supporting a wonderf…
Environmental Scientist
Job Description and Duties Please note: this is a re-advertisement. If you have already applied for this vacancy, your application is being considered and there is no need to re-apply. Position…
Server / Waitstaff
At Waffle House, we are not in the food business. We are in the People Business and we are hiring immediately for full time and part time cooks for (All Shifts). Being in the People Business, we don…