Utilization Review Specialist

Lifepoint Health • Hot Springs, AR

1d • Onsite

About The Position

Utilization Review Specialist facilitates clinical reviews on all patient admissions and continued stays. UR analyzes patient records to determine legitimacy of admission, treatment, and length of stay and interfaces with managed care organizations, external reviewers, and other payers. UR advocates on behalf of patients with substance abuse, dual diagnosis, psychiatric or emotional disorders to manage care providers for necessary treatment. UR contacts external case managers/managed care organizations for certification of insurance benefits throughout the patient’s stay and assists the treatment team in understanding the insurance company’s requirements for continued stay and discharge planning. Additional responsibilities include:

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 services

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.

Participate 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.

Ensure appeals are completed thoroughly and on a timely basis.

Interface with managed care organizations, external reviews, and other payers.

Communicate with physicians to schedule peer to peer reviews.

Accurately report denials.

Other job duties as assigned.

Requirements

• Bachelor’s degree required.
• CPR certification preferred.
• Crisis Prevention Training (CPI) preferred.
• May be required to work flexible hours and overtime.

Nice To Haves

• Master’s degree preferred.
• Previous utilization review experience in a psychiatric healthcare facility preferred.
• Current unencumbered clinical license preferred.

Responsibilities

• 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.
• Advocates on behalf of patients with substance abuse, dual diagnosis, psychiatric or emotional disorders to manage care providers for necessary treatment.
• Contacts external case managers/managed care organizations for certification of insurance benefits throughout the patient’s stay.
• Assists the treatment team in understanding the insurance company’s requirements for continued stay and discharge planning.
• 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 services.
• 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.
• Participate 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.
• Ensure appeals are completed thoroughly and on a timely basis.
• Communicate with physicians to schedule peer to peer reviews.
• Accurately report denials.

Benefits

• Health (Medical, Dental, Vision) and 401K Benefits for full-time employees
• Competitive Paid Time Off
• Short-term and Long-term disability 100% paid for by the company
• Employee Assistance Program – mental, physical, and financial wellness assistance
• Loan repayment, tuition reimbursement and scholarship opportunities for qualified candidates
• Professional development opportunities, apprenticeship programs, and certification assistance

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level