Utilization Review Specialist

About the role

We are seeking a Utilization Review Specialist to join our team at Copper Springs East Behavioral Health. This position plays a crucial role in ensuring that patients receive appropriate and timely care while advocating for their needs.

Responsibilities

• Facilitate clinical reviews for all patient admissions and continued stays.
• Analyze patient records to determine the appropriateness of admission, treatment, and length of stay, and interface with managed care organizations, external reviewers, and other payers.
• Advocate on behalf of patients with substance use disorders, dual diagnoses, psychiatric conditions, or emotional disorders to managed care providers to obtain necessary treatment.
• Contact external case managers and managed care organizations to certify insurance benefits throughout the patient's stay and assist the treatment team in understanding insurance requirements for continued stay and discharge planning.
• Demonstrate knowledge of clinical criteria and managed care requirements for inpatient and outpatient authorization, and advocate on behalf of patients to secure coverage for needed services.
• Complete pre-certifications and re-certifications for inpatient and outpatient services and report denials and authorization information to the designated resource.
• Communicate actively with the interdisciplinary team to obtain pertinent information and provide updates on authorizations.
• Participate in treatment team meetings to ensure staff understand coverage requirements and gather information for communication with external agencies.
• Work with the Director of Nursing (DON) to ensure documentation requirements are met.
• Ensure appeals are completed thoroughly and in a timely manner.
• Interface with managed care organizations, external reviewers, and other payers.
• Communicate with physicians to schedule peer-to-peer reviews.
• Accurately report denials.

Requirements

• Bachelor's degree required. Master's degree preferred.
• Current unencumbered clinical license strongly preferred.
• CPR certification and Crisis Prevention Training (CPI) preferred.
• May be required to work flexible hours and overtime.

Qualifications

• Experience in healthcare administration or related field.
• Strong analytical and problem-solving skills.
• Excellent communication and interpersonal skills.
• Knowledge of healthcare regulations and policies.

Skills

• Proficiency in utilizing healthcare software systems.
• Ability to manage multiple tasks and meet deadlines.
• Strong organizational and time management skills.

Benefits

Multiple levels of medical, dental, and vision coverage for full-time and part-time employees. Financial protection and PTO, including life, accident, critical illness, hospital indemnity insurance, short- and long-term disability, paid family leave, and paid time off. Higher education and certification tuition assistance, loan assistance, and a 401(k) retirement package with company match. Employee well-being programs, including mental, physical, and financial wellness initiatives. Professional development opportunities, including ongoing learning and career advancement.

Pay

Competitive salary commensurate with experience.

Schedule

Full-time position with flexible hours and potential for overtime.

Why join us

We offer comprehensive benefits, professional development opportunities, and a supportive work environment. Join us in making communities healthier.

Additional Information

Copper Springs East Behavioral Health is an Equal Opportunity Employer. Lifepoint Health is a diverse healthcare delivery network committed to equal employment opportunity.