Utilization Review Specialist

Memorial Physician Practices; Raleigh (NC); On-site; USD 60,000 - 85,000; Full time

Job summary

Lifepoint Behavioral Health's Triangle Springs in Raleigh is seeking a Utilization Review Specialist to review patient admissions and ongoing stays. You will analyze records to confirm eligibility, coordinate with managed care and external reviewers, and support the treatment team in discharge planning.

The role emphasizes collaboration with physicians, case managers, and payers to ensure appropriate, efficient care and coverage across services.

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 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.
• Interface with managed care organizations, external reviews, and other payers.
• Communicate with physicians to schedule peer-to-peer reviews.

Skills

Communication skills

Team collaboration

Clinical judgment

Education

Bachelor's degree

Master's degree preferred

Job description

Your experience matters

Lifepoint Behavioral Health is part of Lifepoint Health, a diversified healthcare delivery network with facilities coast to coast. Triangle Springs is a 77-bed behavioral health hospital located in Raleigh, North Carolina, providing care for patients with mental health and substance use disorders. We are driven by a profound commitment to prioritize your well-being so you can provide exceptional care to others. As a Registered Nurse (RN) 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.

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 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.

Job 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 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.
• Interface with managed care organizations, external reviews, and other payers.
• Communicate with physicians to schedule peer-to-peer reviews.

What we're looking for

• 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.

Why join us

We believe that investing in our employees is the first step to providing excellent patient care. In addition to your base compensation, this position also offers:

• 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: Tuition reimbursement and 401(k) retirement package with company match
• Employee Well-being: Mental, physical, and financial wellness programs, including Employee Assistance Program and discount programs
• Professional Development: Ongoing learning and career advancement opportunities
• Additional Perks: Shift differentials and set schedules

EEOC Statement

Lifepoint Behavioral Health is an Equal Opportunity Employer. Lifepoint Behavioral Health is committed to Equal Employment Opportunity for all applicants and employees and complies with all applicable laws prohibiting discrimination and harassment in employment.

Lifepoint Health is a leader in community-based care and driven by a mission of Making Communities Healthier. Our diversified healthcare delivery network spans 29 states and includes 63 community hospital campuses, 32 rehabilitation and behavioral health hospitals, and more than 170 additional sites of care across the healthcare continuum, such as acute rehabilitation units, outpatient centers and post-acute care facilities. We believe that success is achieved through talented people. We want to create places where employees want to work, with opportunities to pursue meaningful and satisfying careers that truly make a difference in communities across the country.