Utilization Specialist - Full Time

Location: Onsite only at San Jose Behavioral Health, a 133-bed acute psychiatric hospital in San Jose serving adults and adolescents with behavioral and mental health disorders.

About the role

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, pre-certification review following plan authorization guidelines, coordinating discharge planning, and providing feedback on documentation processes. The role serves as a resource to the clinical team regarding approved criteria, practice guidelines, and alternative treatment options.

Responsibilities

• Act as liaison between managed care organizations and the facility professional clinical staff.
• Conduct reviews of insurance plans or other managed care organizations (MCOs) and coordinate communication concerning reimbursement requirements.
• Monitor patient length of stay and extensions; 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.
• 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

• Associate Degree in Nursing (LPN/LVN/RN) required; Bachelor’s or Master’s degree in Social Work, Behavioral Health, Mental Health, Nursing, or other related health field preferred.
• Two or more years of experience with the population of the facility preferred.
• Previous experience in utilization management preferred.
• Current clinical professional license or certification (e.g., LMFT, LMSW, LCSW, LPC, LPC-I) within the state where the facility provides services.
• CPR and de-escalation and restraint certification required (training available upon hire and offered by facility).

Pay

• 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)