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Utilization Review Specialist

Company: Pacific Grove Hospital
Location: Riverside
Posted on: January 12, 2021

Job Description:

PURPOSE STATEMENT:Proactively monitor utilization of services for patients to optimize reimbursement for the facility.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'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.Equal Opportunity Employer/Protected Veterans/Individuals with DisabilitiesThe contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)

Keywords: Pacific Grove Hospital, Riverside , Utilization Review Specialist, Other , Riverside, California

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