Specialist, Utilization Review

Copper Springs East

Job Title: Utilization Review Specialist

Job Type: PRN (as needed)

Your experience matters

At Copper 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.

What we offer

Fundamental to providing great care is supporting and rewarding our team. In addition to your base compensation, this position also offers:

• Comprehensive medical, dental, and vision plans, plus flexible-spending and health- savings accounts
• Competitive paid time off
• 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.

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.
• 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.

Minimum Qualifications

Education:

• Bachelor's degree required. Master's degree preferred.

License:

• Current unencumbered clinical license strongly preferred.

Certifications:

• CPR certification and Crisis Prevention Training (CPI) preferred. May be required to work flexible hours and overtime.

Physical, Mental, and Special Demands

• Ability to sit and stand (at least two-thirds of the shift) and walk (possibly one-third of the shift).
• Ability to reach above, or below waist height, kneel, bend, stoop, turn, and twist (occasionally to frequently).
• Visual ability to read charts, treatment plans, financial documents, computer screen and typewritten materials.
• Ability to frequently push/pull wheeled carts to 100 pounds.
• Ability to frequently lift and carry 10 lbs.; occasionally 20 to 50 lbs.
• Ability to work in an environment where chemicals are frequently used for cleaning, where medical and electrical hazards may be present and where dust, mist and steam are frequently generated in housekeeping tasks.
• Ability to work at a rapid pace and perform a variety of repetitive duties.

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.