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Utilization Review Consultant

Company: San Jose Behavioral Health
Location: San Jose
Posted on: August 3, 2020

Job Description:

Summary:San Jose Behavioral Health is currently seeking an experienced Utilization Review Specialist to join our growing team. The Utilization Review Specialist coordinates and assesses the inpatient census for appropriate alternate health care service needs. Responsibilities include preforming 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.ESSENTIAL FUNCTIONS:Proactively monitor utilization of services for patients to optimize reimbursement for the facility.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.EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:Associate''s degree in nursing (LPN or RN) required. Bachelor''s or Masters 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.PandoLogic. Keywords: Utilization Review Consultant, Location: San Jose, CA - 95192by Jobble

Keywords: San Jose Behavioral Health, San Jose , Utilization Review Consultant, Professions , San Jose, California

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