Utilization Review Specialist

We Offer a Full Of Benefits Ranging From

• 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

Hourly Range: $25.00 – $37.47

Pacific Grove Hospital is a nationally recognized 68 bed acute psychiatric and chemical dependency treatment center offering inpatient & outpatient services for psychiatric illnesses, addictions & co-occurring disorders. Our hospital offers comprehensive training, dynamic leadership, and personalized support so you can achieve your greatest potential.

• 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.

• 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.

• 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.