Serenity Knolls
Location
Forest Knolls, California
The specialist will proactively monitor service utilization to optimize facility reimbursement by acting as a liaison between managed care organizations and clinical staff, conducting necessary reviews, and managing communication regarding reimbursement requirements. Key duties include monitoring patient length of stay, gathering utilization statistics, conducting quality reviews for medical necessity, facilitating peer reviews, and managing the appeal process for denied stays.
A high school diploma or equivalent is required, though an Associate's, Bachelor's, or Master’s degree in a related health field is preferred. Candidates must have clinical experience or two or more years working with the facility's population, with prior utilization management experience being preferred, and must obtain CPR and de-escalation/restraint certifications.
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. SERKNO #LI-SKTC
Part-Time Housing Navigator (limited two years)
San Francisco County | Home Care Aide/Caregiver (HCA/CG)
Medication Technician
Laboratory Associate III
Surgical Technician II
General Dentist
Phlebotomist II
RN-STAFF/CLIN NURSE-Radiology-Special Procedures- 40HR Day Shift (8-630 with rotation)
RN-STAFF/CLIN NURSE-4B-Medical Surgical- 36HR Night Shift
Phlebotomist II
RN Case Manager Hospice
Patient Care Technician | CICU