Utilization Specialist Full-time

​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! 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 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