Specialist, Utilization Review

At Columbus 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. 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. What we offer Comprehensive medical, dental, and vision plans, plus flexible‑spending and health‑savings accounts Competitive paid time off and 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 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. 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. Additional Requirements: CPR certification and Crisis Prevention Training (CPI) preferred. Essential Functions 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 service. 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. Supervisory Responsibilities Manage the work of others, including planning, assigning, scheduling and reviewing work, ensures quality standards. Responsible for hiring, terminating, training and developing, reviewing performance and administering corrective action for staff. EEOC Statement Columbus Springs - East is committed to providing Equal Employment Opportunities for all applicants and employees and complies with all applicable laws prohibiting discrimination against any employee or applicant for employment because of color, race, sex, age, religion, national origin, disability, genetic information, gender identity, sexual orientation, veterans' status or any other basis protected by applicable federal, state or local law. #J-18808-Ljbffr Memorial Physician Practices