Specialist, Utilization Review

Lifepoint Health • Avondale, AZ

2d

About The Position

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.

Requirements

• Bachelor’s degree is required. 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.
• May be required to work flexible hours and overtime

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