Pacific Grove·Riverside, California
The specialist monitors the utilization of services to optimize facility reimbursement and acts as a liaison between managed care organizations and clinical staff. Key duties include conducting medical necessity reviews, managing the appeal process for denied stays, and providing staff training on documentation requirements.
Overview Pacific Grove Hospital in Riverside, CA., is a leader in behavioral healthcare, providing superior healthcare treatment to the people, communities, and military installations we serve. We are a private inpatient 68 bed acute psychiatric facility with out-patient services, dedicated to the treatment of behavioral health and substance abuse services. Come join TEAM PGH as a UR Specialist! Flexible scheduling Competitive Pay Employee Assistance Program (EAP) Hourly pay range: $31-50 DOE and licensure held 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: Required Education: High school diploma or equivalent. Preferred Education: 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. 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.
A high school diploma is required, while degrees in Social Work, Nursing, or Mental Health are preferred. Candidates must have clinical experience or at least two years of experience with the facility's population, along with CPR and de-escalation certifications.
Market context
In California, behavioral-health roles tied to substance use disorder counseling and case management are typically supported by ongoing community and treatment-program demand. These positions are competitive because employers often look for a high school diploma, at least 2 years of SUD counseling or case management experience, and current Registered or Certified Drug and Alcohol Counselor status. Review the AI-summarized requirements and benefits here to quickly compare fit and note that professional development and paid continuing education are listed as benefits.
