Utilization Review Specialist

Lifepoint Health • Tampa, FL

1d

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 managed 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.

Requirements

• Bachelor’s degree required.
• CPR certification preferred.
• Crisis Prevention Training (CPI) preferred.

Nice To Haves

• Master’s degree preferred.
• Previous utilization review experience in a psychiatric healthcare facility 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 managed 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.
• Complete 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.

Benefits

• Comprehensive medical, dental, and vision plans
• Flexible-spending and health-savings accounts
• Competitive paid time off
• Extended illness bank package for full-time employees
• Income-protection programs, such as life, accident, critical-injury insurance, short- and long-term disability, and identity theft coverage
• Tuition reimbursement
• Loan assistance
• 401(k) matching
• Employee assistance program including mental, physical, and financial wellness
• Professional development and growth opportunities

What This Job Offers

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