Utilization Review Specialist

VVSD San Diego, CA
  • Depends on experience
  • Full Time
  • Health Insurance, Dental Insurance, Vision Insurance
  • Employer Unlikely 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 RN Case Manager. 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 Medical Necessity criteria to effectively communicate plans of care to insurance case managers, facility staff, and healthcare partners.
  • 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, intervening as necessary and appropriate to ensure that the documented plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis:
    • Completion, documenting and reporting diagnostic testing, treatment plan and discharge plan;
    • Documenting modifications of plan of care, as necessary, to meet the ongoing needs of the patient;
    • Preparation of communications to third party payors and other relevant information to the care team (reviews and/or escalations);
    • Assignment of appropriate levels of care with supporting documentation;
    • Entry of working DRG in the electronic information systems;
    • Completion of all required documentation, communication, and escalations (i.e.: to the Medical Director or Director) in the electronic utilization management software program and patient medical records.
    • Secures appropriate referrals to social service, Home Health Services, SNF and other alternate care services in collaboration with the RN Case Manager.
    • Other duties as assigned by COO 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.
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