Utilization Review Specialist, Drug Medi-Cal

VVSD San Diego, CA
  • Depends on experience
  • Full Time
  • Employer Fairly Likely to Respond

Job Summary:

Responsible for the clinical appropriateness (utilization) review of inpatients and observation patients in assigned area of admission and patient placement. Utilization reviews may extend through continued stay and involve discharge planning activities under the direction of the Medical or Program Director. Typically reports to the Director, Utilization/Case Management.

Essential Duties and Responsibilities:

  • Completes Initial, concurrent, Peer Reviews, Expedited Appeal Reviews, and retrospective reviews in a timely manner to ensure continuous coverage.
  • Utilize clinical information and knowledge of ASAM criteria to effectively communicate plans of care to VRC clinical staff and the County of San Diego.
  • Collaborates with the Medical Director and all members of the multidisciplinary team to facilitate utilization management activities for designated area; monitors the patient’s progress based on approved authorization
  • Compiling, documenting and reporting screening forms, treatment plans, Addiction Severity Index, Recommended Level of Care and discharge plan;
  • Documenting modifications of plan of care, as necessary, to meet the ongoing needs of the patient;
  • Preparation of communications to the County of San Diego and other relevant information to the care team (reviews and/or escalations);
  • Assignment of appropriate levels of care with supporting documentation;
  • Entry of working databases;
  • Secures appropriate referrals to other alternate care services in collaboration with the Case Manager.
  • Other duties as assigned by Director or designee


  • Bachelor’s or Master’s degree in Behavioral/Mental Health Field (or related experience)
  • Active License or Credential in a healthcare, social services, or human services field is preferred.
  • A minimum of two years’ experience working with the Utilization Review process is required.
  • Experience in Behavioral Health Care and knowledge of the ASAM criteria
  • Expertise in Psychiatric and Addiction Disorders
  • Knowledge of analyzing data and submitting reports to meet deadlines
  • Excellent professional phone skills
  • Experience maintaining files and records both computerized and hard copy
  • Ability to fluently read, write and communicate in English
  • Must be able to prioritize and switch priorities at a moment’s notice
  • Able to effectively interact, in a professional manner, with a variety of government agencies, state, county, city and federal
  • Ability to comfortably, both mentally and physically, perform all aspects of job description and other duties as assigned by supervisor
  • Must have privately owned vehicle, current driver’s license and proof of current vehicle insurance
  • Ability to work with a diverse population
  • Veteran Status a Plus!

Physical Requirements:

  • Ability to bend and lift light objects
  • Ability to sit for extended periods of time while viewing a computer monitor
  • Dexterity of hands and fingers to operate a computer keyboard
  • Capable of hearing and speaking to exchange information
  • Seeing to read reports and data
  • Must be able to work in a noisy, busy environment.

The Fine Print:

  • If you were a client of VVSD, you must have been out of all programs for a minimum of 2 years
  • Veterans Village of San Diego is an equal opportunity workplace. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity, or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
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