Specialist, Utilization Review

Lifepoint Health; Columbus (OH); On-site; USD 65,000 - 86,000; Full time

Benefits offered by this job

Medical, dental, vision

Paid time off

Insurance protection

Tuition reimbursement

Employee assistance program

Professional development

Job summary

Columbus Springs-East, part of Lifepoint Health, seeks a Utilization Review Specialist to perform clinical reviews of patient admissions and stays. The role interfaces with managed care organizations, advocates for appropriate coverage, and coordinates with the treatment team to ensure compliant discharge planning.

The ideal candidate has a Bachelor's degree (Master's preferred), UR experience in psychiatric settings, and an active clinical license; CPR and CPI certification are a plus.

Qualifications

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

Responsibilities

• 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 service.
• 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.

Education

Bachelor's degree

Master's degree

Job description

Your experience matters

At Columbus Springs-East, we are committed to empowering and supporting a diverse and determined workforce who can drive quality, scalability, and significant impact across our hospitals and communities. In your role, you'll support those that are in our facilities who are interfacing and providing care to our patients and community members. We believe that our collective efforts will shape a healthier future for the communities we serve.

What we offer

• Comprehensive medical, dental, and vision plans, plus flexible-spending and health- savings accounts
• Competitive paid time off and 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, and 401(k) matching
• Employee assistance program including mental, physical, and financial wellness
• Professional development and growth opportunities

How you'll contribute

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.

Qualifications and requirements

• Education: Bachelor's degree required. Master's degree preferred.
• Experience: Previous utilization review experience in a psychiatric healthcare facility preferred.
• License: Current unencumbered clinical license strongly preferred.
• Additional Requirements: CPR certification and Crisis Prevention Training (CPI) preferred

Essential Functions

• 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 service.
• 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.

SUPERVISORY RESPONSIBILITIES

• Manage the work of others, including planning, assigning, scheduling and reviewing work, ensures quality standards. Responsible for hiring, terminating, training and developing, reviewing performance and administering corrective action for staff.

About Us

Columbus Springs - East is a 72 bed hospital located in Columbus, OH, and is part of Lifepoint Health , a diversified healthcare delivery network committed to making communities healthier with acute care, rehabilitation, and behavioral health facilities from coast to coast. From your first day to your next career milestone-your experience matters

EEOC Statement

Columbus Springs - East is committed to providing Equal Employment Opportunities for all applicants and employees and complies with all applicable laws prohibiting discrimination against any employee or applicant for employment because of color, race, sex, age, religion, national origin, disability, genetic information, gender identity, sexual orientation, veterans' status or any other basis protected by applicable federal, state or local law.