Healthcare Utilization & Appeals Specialist

Garner Behavioral Hospital LLC; United States; On-site; USD 65,000 - 85,000; Full time

Job summary

Garner Behavioral Hospital LLC in Raleigh, NC seeks a Utilization Review Specialist to assess admissions, continued stays, and discharge planning using approved criteria to secure authorizations. The role involves coordinating with physicians, payers, and staff; conducting pre-certifications, benefit verification, and documentation; and supporting staff with regulatory updates.

This on-site position offers a comprehensive benefits package and opportunities to contribute to effective patient care

Qualifications

• Graduation from an approved/accredited school of nursing or a Bachelor's degree in social work, behavioral or mental health, or other related health field required.
• Two or more years of direct clinical experience in a psychiatric or mental health setting required.
• Current licensure as an LPN or RN or current clinical professional license or certification, as required, within the state where the facility provides services.

Responsibilities

• Performs admission, concurrent, continued stay, and retrospective reviews using the established hospital criteria.
• Communicates with insurance companies, HMOs, and other entities for approval of inpatient days.
• Appeals all denials and coordinates the appeal process; provides information to physicians to assist in appeals.

Skills

Nursing knowledge

Clinical documentation

Communication with payers

Education

Bachelor's degree in nursing or related health field

Tools

Electronic Medical Records

Job description

Garner Behavioral Hospital LLC in Raleigh, NC seeks a Utilization Review Specialist to assess admissions, continued stays, and discharge planning using approved criteria to secure authorizations. The role involves coordinating with physicians, payers, and staff; conducting pre-certifications, benefit verification, and documentation; and supporting staff with regulatory updates.

This on-site position offers a comprehensive benefits package and opportunities to contribute to effective patient care