National Utilization Management Specialist

RiverMend Health - Santa Monica, CA



RiverMend Health has an exciting opportunity for a talented professional who will provide daily administrative and professional support that enables claims to be correctly processed and retained in accordance with departmental policies and procedures. The specific functions performed by this role are critical in achieving the Revenue Cycle Team’s overall responsibilities involving timely billing and account follow-up. This national employer is on a fast track towards building sustained excellence, innovative methodologies and superior outcomes. In brief, RiverMend Health is an Employer of Choice pursuing only the best and most qualified talent as full time UM Specialist


Professional environment where employee development is a top priority. Competitive pay and benefits. Growth opportunities. Creativity and out of the box thinking is embraced. Work Life Balance is supported.


Overview: The National Utilization Management Specialist (UM) is responsible for conducting medical necessity reviews utilizing InterQual and Milliman Care Guidelines, clinical reviews with third payers (Commercial and Medicaid). The UM specialist will conduct review for both eating disorder and chemically dependent patient in our continuum of care programs across multiple states. The UM specialist will collaborate with the clinical teams on the coordination of safe transitions of care for a defined patient population based one medical necessity. The Utilization Management specialist will perform utilization review every day by looking at all pre-certed admissions, all peer to peer cases and concurrent reviews.

The UM specialist will gather clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to complete the determination/recommendation for the most appropriate level of care status and clinical review to the payers. Along the continuum of care, communicates with providers and other parties to facilitate care/treatment. Identifies opportunities to ensure effectiveness of healthcare services in the most appropriate setting always as well as timely discharge to the most appropriate level of post discharge care.Maintains daily and monthly work logs of all admission, concurrent, focused, or retrospective reviews. Other duties as assigned by Director of Utilization Management.

Job Knowledge:

  • InterQual and Milliman Care Guidelines (Preferred)
  • Clinical Care review/coordination (A MUST)
  • Denial and appeals management experience a MUST
  • Health Information Management a PLUS
  • ASAM knowledge preferable
  • Excellent organization skills
  • Excellent verbal and oral communication


  • Displays documentation and record-keeping expertise
  • Effectively multi-tasks and completes assignments with consistent accuracy
  • Demonstrates financial acumen in analyzing data with subject matter expertise and makes meaningful recommendations
  • Shows attention to detail in all job responsibilities
  • Works consistently with a sense of urgency
  • Shows advanced computer skills in work completion to include report preparation
  • Self identifies and pursues appropriate developmental opportunities


  • Education – Bachelor’s degree required, Master ’s Degree preferred.
  • Experience – Minimum of 5 years of direct experience in a mental health and/or addiction treatment setting;
  • Skills – Excellent verbal and written communication skills. Proficient PC skills. Working knowledge of medical terminology, anatomy and physiology, disease and pathology. Analyze patient records and participate in interdisciplinary collaboration with professional staff. Problem solving and good decision-making skills. Ability to determine medical necessity, appropriateness and level of care. Conflict resolution skills. (Electronic Medical Record/ Medical Billing Systems, SharePoint, Excel, Word, Office 365) and data entry skills.
  • Qualifications: Utilization Management aptitude, attention to detail and highly organized, A demonstrated commitment to high professionalism, interpersonal skills, and ethical standards. Strong written and verbal communication skills. Excellent time management and organizational skills. Ability to maintain a sense of professionalism at all time. Ability to work independently. Demonstrated teamwork and flexibility in a fast-paced changing environment.


  • The National Utilization Management Specialist (UM) is a full-time position working the hours required to meet job expectations.
  • Scheduled and unscheduled performance reviews are given according to Company policies.
  • Limited travel may be required.
  • Employment with RiverMend Health is “at will” and employment may be terminated at any time with or without cause or notice.


  • The job expectations statements above are intended to describe the general nature and level of work being performed by employees and are not to be construed as an exhaustive list of responsibilities, duties, and skills. The job responsibilities above may be modified to meet changing business needs.
  • RiverMend Health is an Equal Opportunity Employer. The Company makes all selection and other employment decisions without regard to race, color, religion, sex, national origin, age, disability, genetic orientation, or any other characteristic protected by applicable law. In addition, the Company provides reasonable accommodations for applicants or employees with physical or mental disabilities in accordance with applicable law(s). If an accommodation is required to apply for employment, or to perform the essential responsibilities of a position you seek, please contact Human Resources so appropriate arrangements can be made.


Job Type: Full-time


  • Mental health and/or addiction treatment setting: 5 years (Required)


  • Master's (Preferred)

Work authorization:

  • United States (Required)