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 inpatie... more details
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.
Utilization Review Specialist include
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.
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.
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