Lifepoint Health®
Specialist, Utilization Review
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Specialist, Utilization Review
role at
Lifepoint Health® .
Position Summary The Utilization Review Specialist is responsible for managing and coordinating the utilization review process for inpatient and outpatient behavioral health services. This role ensures medical necessity, timely authorizations, regulatory compliance, and effective communication with managed care organizations. The Specialist works collaboratively with clinical teams, the assessment department, and leadership to support appropriate level‑of‑care decisions, optimize reimbursement, and reduce denials. This position requires a minimum of three years of utilization review experience within a behavioral health hospital setting.
Qualifications
Bachelor's degree in Nursing, Social Work, Healthcare Administration, or a related field preferred
High School Diploma/GED required
Minimum of 3 years of utilization review experience in a behavioral health hospital (inpatient and/or outpatient)
Demonstrated experience with managed care authorizations, concurrent reviews, and payer communication
Active clinical license (RN, LCSW, LMSW, LPC, LMFT) preferred
CPR and Handle with Care (HWC) certification required within 30 days of hire
Knowledge of medical necessity criteria (e.g., InterQual, MCG)
Strong documentation, time management, and communication skills
Ability to work flexible hours and occasional overtime as needed
Ability to sit or stand for extended periods, move throughout the facility, bend, reach, stoop, and perform light lifting
Visual and cognitive ability to review clinical documentation, payer guidelines, and electronic health records
Ability to work efficiently in a fast‑paced healthcare environment with frequent interruptions, meeting deadlines and managing multiple priorities
Key Responsibilities
Conduct concurrent and retrospective utilization reviews to ensure medical necessity and payer compliance
Manage pre‑authorizations and continued stay reviews for inpatient and outpatient services
Communicate clinical information to managed care organizations within required timeframes
Track, document, and enter authorization data accurately into the patient database and UR tracking tools
Coordinate, schedule, and follow up on peer‑to‑peer reviews with medical providers and payers
Collaborate with the assessment department to ensure authorization prior to admission
Assist with discharge reviews, including timely notification and submission of discharge clinical information
Monitor authorization status to prevent denials and identify trends or barriers impacting length of stay
Ensure Medicare certification letters are completed and signed by the appropriate provider
Support UR Manager or Director with reporting, audits, and performance improvement initiatives
Maintain organized, accurate electronic and paper files in accordance with regulatory standards
Physical, Mental, and Special Demands
Ability to sit or stand for extended periods and move throughout the facility as needed
Ability to bend, reach, stoop, and perform light lifting
Visual and cognitive ability to review clinical documentation, payer guidelines, and electronic health records
Ability to work efficiently in a fast‑paced healthcare environment with frequent interruptions
Ability to meet deadlines, manage multiple priorities, and perform repetitive data‑related tasks
Seniority Level Mid‑Senior level
Employment type Full‑time
Job function Other
Industries Hospitals and Health Care
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Specialist, Utilization Review
role at
Lifepoint Health® .
Position Summary The Utilization Review Specialist is responsible for managing and coordinating the utilization review process for inpatient and outpatient behavioral health services. This role ensures medical necessity, timely authorizations, regulatory compliance, and effective communication with managed care organizations. The Specialist works collaboratively with clinical teams, the assessment department, and leadership to support appropriate level‑of‑care decisions, optimize reimbursement, and reduce denials. This position requires a minimum of three years of utilization review experience within a behavioral health hospital setting.
Qualifications
Bachelor's degree in Nursing, Social Work, Healthcare Administration, or a related field preferred
High School Diploma/GED required
Minimum of 3 years of utilization review experience in a behavioral health hospital (inpatient and/or outpatient)
Demonstrated experience with managed care authorizations, concurrent reviews, and payer communication
Active clinical license (RN, LCSW, LMSW, LPC, LMFT) preferred
CPR and Handle with Care (HWC) certification required within 30 days of hire
Knowledge of medical necessity criteria (e.g., InterQual, MCG)
Strong documentation, time management, and communication skills
Ability to work flexible hours and occasional overtime as needed
Ability to sit or stand for extended periods, move throughout the facility, bend, reach, stoop, and perform light lifting
Visual and cognitive ability to review clinical documentation, payer guidelines, and electronic health records
Ability to work efficiently in a fast‑paced healthcare environment with frequent interruptions, meeting deadlines and managing multiple priorities
Key Responsibilities
Conduct concurrent and retrospective utilization reviews to ensure medical necessity and payer compliance
Manage pre‑authorizations and continued stay reviews for inpatient and outpatient services
Communicate clinical information to managed care organizations within required timeframes
Track, document, and enter authorization data accurately into the patient database and UR tracking tools
Coordinate, schedule, and follow up on peer‑to‑peer reviews with medical providers and payers
Collaborate with the assessment department to ensure authorization prior to admission
Assist with discharge reviews, including timely notification and submission of discharge clinical information
Monitor authorization status to prevent denials and identify trends or barriers impacting length of stay
Ensure Medicare certification letters are completed and signed by the appropriate provider
Support UR Manager or Director with reporting, audits, and performance improvement initiatives
Maintain organized, accurate electronic and paper files in accordance with regulatory standards
Physical, Mental, and Special Demands
Ability to sit or stand for extended periods and move throughout the facility as needed
Ability to bend, reach, stoop, and perform light lifting
Visual and cognitive ability to review clinical documentation, payer guidelines, and electronic health records
Ability to work efficiently in a fast‑paced healthcare environment with frequent interruptions
Ability to meet deadlines, manage multiple priorities, and perform repetitive data‑related tasks
Seniority Level Mid‑Senior level
Employment type Full‑time
Job function Other
Industries Hospitals and Health Care
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