Behavioral Health Social Worker, Utilization Review, Days (onsite)

Join Palestine Regional Medical Center in Palestine, TX, a 150-bed hospital that has recently earned the prestigious Leapfrog “A” Safety Grade, the Platinum Award for quality from parent-company ScionHealth, and certification as a Chest Pain Center and Level IV Trauma facility. Palestine Regional provides a range of comprehensive care, including the latest in diagnostic, therapeutic, and rehabilitative services, both on an inpatient and outpatient basis. Palestine Regional is an integral part of the local community, giving you the chance to grow your career while making a real impact close to home.

Job Summary

The Social Worker-Utilization Review monitors adherence to the hospital's utilization review plan to ensure appropriate use of hospital services, admissions, and extended stays. The Social Worker-Utilization Review performs pre-certification, concurrent review, and discharge planning in accordance with applicable guidelines and acts as a liaison to support safe, timely, and medically necessary care.

Essential Functions

• Ensures the medical necessity and appropriateness of all hospital admissions per established criteria
• Performs concurrent medical record reviews to justify continued stay and documents appropriately
• Coordinates with care team to facilitate timely and effective discharge planning
• Communicates with third-party payers and managed care entities to provide required documentation
• Collaborates with social services and case management to streamline patient transitions and reduce readmissions
• Reviews and monitors patient charts in alignment with medical staff performance improvement metrics
• Contributes to organizational quality goals and achieves performance targets in a timely manner

Knowledge/Skills/Abilities/Expectations

• Strong clinical assessment and critical thinking skills
• Ability to interpret medical records, criteria, and regulations
• Knowledge of utilization review processes, discharge planning, and payer requirements
• Proficient in communication and coordination with interdisciplinary teams
• Skilled in documentation, confidentiality practices, and health information systems
• Demonstrates resilience, adaptability, and the ability to manage stress effectively
• Frequent use of computers and telephone
• Must be able to sit or stand for prolonged periods
• Occasional lifting of up to 25 pounds
• Frequent walking and light movement required during audits or rounding
• Hospital setting with exposure to general healthcare conditions
• May involve contact with patients, families, and medical records
• Potential exposure to communicable diseases, bloodborne pathogens, and chemicals
• Fast-paced environment requires focus, accuracy, and confidentiality