Specialist, Utilization Review

Lifepoint Health • Avondale, AZ

1d

About The Position

Your experience matters Copper Springs is part of Lifepoint Health, a diversified healthcare delivery network with facilities coast to coast. We are driven by a profound commitment to prioritize your well-being so you can provide exceptional care to others. As a Utilization Review Specialist joining our team, you’re embracing a vital mission dedicated to making communities healthier ®. Join us on this meaningful journey where your skills, compassion and dedication will make a remarkable difference in the lives of those we serve. How you'll contribute A Utilization Review Specialist who excels in this role: Facilitate clinical reviews for all patient admissions and continued stays. Analyze patient records to determine the medical necessity and appropriateness of admissions, treatment, and length of stay. Collaborate with managed care organizations, external reviewers, and payers to support coverage determinations. Advocate for patients with substance use, dual diagnosis, psychiatric, or emotional disorders to ensure access to medically necessary treatment. Communicate with external case managers and payers to obtain and maintain insurance authorizations throughout the patient stay. Partner with the interdisciplinary treatment team to support care planning and ensure timely, appropriate utilization of services. Apply knowledge of clinical criteria and managed care requirements for inpatient and outpatient authorizations. Complete pre-certifications and re-certifications for inpatient and outpatient services. Communicate authorization updates, denials, and approvals to designated stakeholders in a timely manner. Actively collaborate with the interdisciplinary team to gather clinical information and provide authorization updates. Participate in treatment team meetings to ensure awareness of coverage status and gather information for payer communication. Work closely with the Director of Nursing (DON) to ensure documentation requirements are met. Prepare and submit thorough, timely appeals for denied services. Coordinate with physicians to schedule peer-to-peer reviews with payers. Accurately track and report denials, authorizations, and payer communications.

Requirements

• Education: Bachelor’s degree is required.
• Licenses/Certifications Current unencumbered clinical license is strongly preferred.
• CPR certification and Crisis Prevention Training (CPI) preferred.
• Experience: Previous utilization review experience in a psychiatric healthcare facility preferred.
• May be required to work flexible hours and overtime

Nice To Haves

• Master’s degree preferred.
• Current unencumbered clinical license is strongly preferred.
• CPR certification and Crisis Prevention Training (CPI) preferred.
• Previous utilization review experience in a psychiatric healthcare facility preferred.

Responsibilities

• Facilitate clinical reviews for all patient admissions and continued stays.
• Analyze patient records to determine the medical necessity and appropriateness of admissions, treatment, and length of stay.
• Collaborate with managed care organizations, external reviewers, and payers to support coverage determinations.
• Advocate for patients with substance use, dual diagnosis, psychiatric, or emotional disorders to ensure access to medically necessary treatment.
• Communicate with external case managers and payers to obtain and maintain insurance authorizations throughout the patient stay.
• Partner with the interdisciplinary treatment team to support care planning and ensure timely, appropriate utilization of services.
• Apply knowledge of clinical criteria and managed care requirements for inpatient and outpatient authorizations.
• Complete pre-certifications and re-certifications for inpatient and outpatient services.
• Communicate authorization updates, denials, and approvals to designated stakeholders in a timely manner.
• Actively collaborate with the interdisciplinary team to gather clinical information and provide authorization updates.
• Participate in treatment team meetings to ensure awareness of coverage status and gather information for payer communication.
• Work closely with the Director of Nursing (DON) to ensure documentation requirements are met.
• Prepare and submit thorough, timely appeals for denied services.
• Coordinate with physicians to schedule peer-to-peer reviews with payers.
• Accurately track and report denials, authorizations, and payer communications.

Benefits

• Comprehensive Benefits : Multiple levels of medical, dental and vision coverage for full-time and part-time employees.
• Financial Protection & PTO : Life, accident, critical illness, hospital indemnity insurance, short- and long-term disability, paid family leave and paid time off.
• Financial & Career Growth : Higher education and certification tuition assistance, loan assistance and 401(k) retirement package and company match.
• Employee Well-being : Mental, physical, and financial wellness programs (free gym memberships, virtual care appointments, mental health services and discount programs).
• Professional Development : Ongoing learning and career advancement opportunities.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees