Utilization Specialist - PRN

Salary Range: LMFT/LPCC/LCSW $33.00–$50.00 per hour (based on experience). LVN: $33.00–$43.75 per hour (based on experience). RN: $60.00+ per hour (based on experience). Location: ONSITE ONLY. San Jose Behavioral Health is currently seeking a Utilization Review Specialist - PRN to assist the Utilization Department staff with comprehensive inpatient care and treatment within our 133-bed Acute Psychiatric Hospital. The hospital offers comprehensive inpatient treatment for adults and adolescents with a range of behavioral and mental health disorders. Purpose Statement 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. Also, coordinate with appropriate discharge planning processes, providing feedback on documentation processes, and function as a resource to the clinical team regarding approved criteria, practice guidelines, and alternative treatment options. 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. Education/Experience/Skill Requirements Associate Degree in Nursing (LPN/LVN/RN) required. Bachelor’s or Master’s degree in Social Work, Behavioral Health or Mental Health, Nursing or another related health field preferred. Two or more years of experience with the population of the facility preferred. Previous experience in utilization management preferred. Licenses/Designations/Certifications LMFT, 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. CPR and de‑escalation and restraint certification required (training available upon hire and offered by facility). Additional Regulatory Requirements While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances (e.g., emergencies, changes in workload, rush jobs or technological developments) dictate. 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. Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities. #J-18808-Ljbffr San Jose Behavioral Health Hospital