Specialist, Utilization Review

What We Offer

• Comprehensive medical, dental, and vision plans, plus flexible-spending and health-savings accounts
• Cashiered paid time off and extended illness bank package for full-time employees
• Income-protection programs, such as life, accident, critical-injury insurance, short- and long-term disability, and identity theft coverage
• Tuition reimbursement, loan assistance, and 401(k) matching
• Employee assistance program including mental, physical, and financial wellness
• Professional development and growth opportunities

How You'll Contribute

• Facilitates clinical reviews on all patient admissions and continued stays
• Analyzes patient records to determine legitimacy of admission, treatment, and length of stay
• Interfaces with managed care organizations, external reviewers and other payers
• Affords on behalf of patients with substance abuse, dual diagnosis, psychiatric or emotional disorders to managed care providers for necessary treatment
• Contacts external case managers/managed care organizations for certification of insurance benefits throughout the patient's stay
• Aids the treatment team in understanding the insurance company's requirements for continued stay and discharge planning

Qualifications And Requirements

• Education: Bachelor's degree required. Master's degree preferred.
• Experience: Previous utilization review experience in a psychiatric healthcare facility preferred.
• Licenses: Current unencumbered clinical license strongly preferred.
• Additional Requirements: CPR certification and Crisis Prevention Training (CPI) preferred.

Essential Functions

• Displays knowledge of clinical criteria, managed care requirements for inpatient and outpatient authorization and advocates on behalf of the patient to secure coverage for needed service.
• Completes pre and re-certifications for inpatient and outpatient services.
• Reports appropriate denial, and authorization information to designated resource.
• Actively communicates with interdisciplinary team to acquire pertinent information and give updates on authorizations.
• Participates in treatment teams to ensure staff have knowledge of coverage and to collect information for communication with agencies.
• Works with DON to ensure documentation requirements are met.
• Ensures appeals are completed thoroughly and on a timely basis.
• Interfaces with managed care organizations, external reviews, and other payers.
• Communicates with physicians to schedule peer to peer reviews.
• Accurately reports denials.
• Manages the work of others, including planning, assigning, scheduling and reviewing work, ensures quality standards.
• Responsible for hiring, terminating, training and developing, reviewing performance and administering corrective action for staff.

About Us

Columbus Springs - East is a 72 bed hospital located in Columbus, OH, and is part of Lifepoint Health, a diversified healthcare delivery network committed to making communities healthier® with acute care, rehabilitation, and behavioral health facilities from coast to coast. From your first day to your next career milestone-your experience matters EEOC Statement Columbus Springs - East is committed to providing Equal Employment Opportunities for all applicants and employees and complies with all applicable laws prohibiting discrimination against any employee or applicant for employment because of color, race, sex, age, religion, national origin, disability, genetic information, gender identity, sexual orientation, veterans' status or any other basis protected by applicable federal, state or local law. Lifepoint Health is a leader in community-based care and driven by a mission of Making Communities Healthier. Our diversified healthcare delivery network spans 29 states and includes 63 community hospital campuses, 32 rehabilitation and behavioral health hospitals, and more than 170 additional sites of care across the healthcare continuum, such as acute rehabilitation units, outpatient centers and post-acute care facilities. We believe that success is achieved through talented people. We want to create places where employees want to work, with opportunities to pursue meaningful and satisfying careers that truly make a difference in communities across the country.