Specialist, Utilization Review

LifePoint Health•Georgetown, TX

About The Position

The Utilization Review Specialist is responsible for managing and coordinating the utilization review process for inpatient and outpatient behavioral health services. This role ensures medical necessity, timely authorizations, regulatory compliance, and effective communication with managed care organizations. The Specialist works collaboratively with clinical teams, the assessment department, and leadership to support appropriate level-of-care decisions, optimize reimbursement, and reduce denials. This position requires a minimum of three years of utilization review experience within a behavioral health hospital setting.

Requirements

Minimum of 3 years of utilization review experience in a behavioral health hospital (inpatient and/or outpatient)
Demonstrated experience with managed care authorizations, concurrent reviews, and payer communication
Active clinical license (RN, LCSW, LMSW, LPC, LMFT) preferred
CPR and Handle with Care (HWC) certification required within 30 days of hire
Knowledge of medical necessity criteria (e.g., InterQual, MCG)
Strong documentation, time management, and communication skills
Ability to work flexible hours and occasional overtime as needed
High School Diploma/GED required
Bachelor's degree in Nursing, Social Work, Healthcare Administration, or a related field preferred

Responsibilities

Conducts concurrent and retrospective utilization reviews to ensure medical necessity and payer compliance
Manages pre-authorizations and continued stay reviews for inpatient and outpatient services
Communicates clinical information to managed care organizations within required timeframes
Tracks, documents, and enters authorization data accurately into the patient database and UR tracking tools
Coordinates, schedules, and follows up on peer-to-peer reviews with medical providers and payers
Collaborates with the assessment department to ensure authorization prior to admission
Assists with discharge reviews, including timely notification and submission of discharge clinical information
Monitors authorization status to prevent denials and identifies trends or barriers impacting length of stay
Ensures Medicare certification letters are completed and signed by the appropriate provider
Supports UR Manager or Director with reporting, audits, and performance improvement initiatives
Maintains organized, accurate electronic and paper files in accordance with regulatory standards