Utilization Specialist

About the role

Serenity Knolls, located in the San Geronimo Valley just 10 minutes west of Fairfax, is a 42‑bed residential treatment center (6 beds designated for detox) serving adults 18 and older. As a 12‑step based, social model residential treatment center, Serenity Knolls combines traditional social models of care with contemporary cognitive behavioral, psychodynamic, and evidence‑based practices. Purpose Statement: Diagnose and treat mental and emotional disorders, whether cognitive, affective or behavioral.

Responsibilities

• 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.

Requirements

• Education: Required: High school diploma or equivalent. Preferred: Associate's, Bachelor's, or Master’s degree in Social Work, Behavioral or Mental Health, Nursing, or a related health field.
• Experience: Clinical experience is required, or two or more years' experience working with the facility's population. Previous experience in utilization management is preferred.
• Licenses/Designations/Certifications: Preferred Licensure: LPN, RN, 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). First aid may be required based on state or facility requirements.

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.

Pay

Pay rate: $28 – $30 per hour. Possible remote position.