Utilization Review Specialist
Lifepoint Health®, Holyoke, MA, United States
Your Experience Matters
At Valley Springs Behavioral Hospital, 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. Our programs offer customized rehabilitation tailored to the specific needs of those recovering from a stroke, brain injury, neurological conditions, trauma, spinal cord injury, amputation or orthopedic injury.
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.
Additional 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.
Participates 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.
Ensures appeals are completed thoroughly and on a timely basis.
Interfaces with managed care organizations, external reviews, and other payers.
Communicates with physicians to schedule peer‑to‑peer reviews.
Accurately reports denials.
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 and an 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
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.
EEOC Statement
Valley Springs Behavioral Hospital is an Equal Opportunity Employer. Valley Springs Behavioral Hospital is committed to Equal Employment Opportunity for all applicants and employees and complies with all applicable laws prohibiting discrimination and harassment in employment.
#J-18808-Ljbffr
At Valley Springs Behavioral Hospital, 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. Our programs offer customized rehabilitation tailored to the specific needs of those recovering from a stroke, brain injury, neurological conditions, trauma, spinal cord injury, amputation or orthopedic injury.
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.
Additional 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.
Participates 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.
Ensures appeals are completed thoroughly and on a timely basis.
Interfaces with managed care organizations, external reviews, and other payers.
Communicates with physicians to schedule peer‑to‑peer reviews.
Accurately reports denials.
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 and an 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
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.
EEOC Statement
Valley Springs Behavioral Hospital is an Equal Opportunity Employer. Valley Springs Behavioral Hospital is committed to Equal Employment Opportunity for all applicants and employees and complies with all applicable laws prohibiting discrimination and harassment in employment.
#J-18808-Ljbffr