Utilization Review Specialist - Advocate for Care

Memorial Physician Practices; Lafayette (IN); On-site; USD 55,000 - 75,000; Full time

Job summary

Sycamore Springs is seeking an Utilization Review Specialist to facilitate clinical reviews for patient admissions and continued stays. The role involves analyzing records to determine legitimacy of admission, treatment, and length of stay, and coordinating with managed care organizations and external reviewers to ensure appropriate coverage.

Essential functions include applying clinical criteria, completing pre- and re-certifications, and communicating with the care team to support treatment

Qualifications

• Bachelor’s Degree
• Previous utilization review experience in a psychiatric healthcare facility 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.
• 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

Job description

Sycamore Springs is seeking an Utilization Review Specialist to facilitate clinical reviews for patient admissions and continued stays. The role involves analyzing records to determine legitimacy of admission, treatment, and length of stay, and coordinating with managed care organizations and external reviewers to ensure appropriate coverage.

Essential functions include applying clinical criteria, completing pre- and re-certifications, and communicating with the care team to support treatment