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Prior Authorization Utilization Review Jobs in Colorado

Capital Rx

Prior Authorization Systems Pharmacist

Denver, CO · On-site

$60 - $72/hr

Perform comprehensive quality control (QC) review of decision trees, questionnaires, and ... Works with Director, Utilization Management on other responsibilities, projects, and initiatives as ...

Capital Rx

Prior Authorization Systems Technician

Denver, CO · On-site

$18 - $21.75/hr

Evaluate and operationalize weekly formulary and utilization management (UM) updates, including ... Conduct intake and pre-review preparation of PA cases by validating member, provider, and clinical ...

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Prior Authorization Utilization Review information

What are the key skills and qualifications needed to thrive as a Prior Authorization Utilization Review specialist?

To thrive as a Prior Authorization Utilization Review Specialist, you need a strong understanding of medical terminology, insurance guidelines, and clinical criteria, often supported by a degree in healthcare or nursing and relevant certification (such as RN or LPN). Familiarity with prior authorization software, electronic health record (EHR) systems, and payer portals is typically required. Attention to detail, strong communication skills, and the ability to multitask help professionals excel in this role. These competencies ensure accurate and timely processing of authorizations, reducing delays in patient care and ensuring compliance with payer requirements.

How do I get into a prior authorization utilization review?

To enter a prior authorization utilization review role, candidates typically need a background in healthcare, nursing, or health administration, along with knowledge of insurance policies and medical coding. Relevant certifications such as Certified Professional Coder (CPC) or Certified Utilization Review Professional (CURP) can enhance prospects, and experience with electronic health records (EHR) systems is often required.

What is a Prior Authorization Utilization Review specialist?

A Prior Authorization Utilization Review specialist is a healthcare professional responsible for evaluating medical service requests to ensure they meet specific criteria for approval before services are provided. Their main role is to review clinical information, verify medical necessity, and ensure compliance with insurance policies and guidelines. They act as a liaison between healthcare providers, insurance companies, and patients to facilitate timely and accurate authorization decisions. This process helps to manage healthcare costs and ensure patients receive appropriate care.

What is the difference between Prior Authorization Utilization Review vs Medical Reviewer?

AspectPrior Authorization Utilization ReviewMedical Reviewer
CredentialsLicensed healthcare professionals, often with certifications in utilization reviewLicensed physicians or healthcare providers with clinical expertise
Work EnvironmentInsurance companies, healthcare organizations, or third-party review firmsHospitals, clinics, insurance companies, or consulting firms
Primary FocusAssessing the necessity of procedures or treatments before approvalEvaluating clinical records to determine medical necessity and appropriateness

While both roles involve clinical assessment, Prior Authorization Utilization Review focuses on pre-authorization decisions for treatments, whereas Medical Review involves detailed clinical evaluation of patient records to determine medical necessity. Both require healthcare credentials and are integral to healthcare quality and cost management.

Is prior authorization utilization review a stressful job?

Prior authorization utilization review can be stressful due to the need for accuracy, attention to detail, and meeting strict deadlines. The role often involves reviewing medical documentation and making quick decisions, which can lead to pressure and workload challenges, especially during high-volume periods.

What are some common challenges faced by professionals in Prior Authorization Utilization Review roles, and how can these be managed?

Professionals in Prior Authorization Utilization Review often encounter challenges such as navigating complex insurance policies, managing high volumes of requests, and ensuring timely communication between providers and payers. Staying organized, developing a thorough understanding of payer guidelines, and maintaining clear, consistent communication are key strategies for managing these challenges. Many teams also rely on workflow management tools and regular team huddles to streamline processes and ensure all cases are handled efficiently.
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Prior Authorization Utilization Review jobs near you

Utilization Review Specialist

Lifepoint Health

Englewood, CO • On-site

$26 - $33/hr

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted 9 days ago

LifePoint Health rating

6.0

Company rating: 6.0 out of 10

Based on 271 frontline employees who took The Breakroom Quiz

748th of 887 rated healthcare providers

Job description

Your experience matters 

Denver Springs is part of Lifepoint Health, a diversified healthcare delivery network with facilities coast to coast. We are driven by a profound commitment to prioritize your well-being so you can provide exceptional care to others. As a Utilization Review Specialist joining our team, you're embracing a vital mission dedicated to making communities healthier . Join us on this meaningful journey where your skills, compassion and dedication will make a remarkable difference in the lives of those we serve.

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.

A Utilization Review Specialist who excels in this role:

  • 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

Bachelors required. Masters preferred. 

Schedule

FT, On-site, anytime between 7am-6pm MST (8 hours a day)

Why join us

We believe that investing in our employees is the first step to providing excellent patient care. In addition to your base compensation, this position also offers: 

  • Comprehensive Benefits: Multiple levels of medical, dental and vision coverage for full-time and part-time employees.
  • Financial Protection & PTO: Life, accident, critical illness, hospital indemnity insurance, short- and long-term disability, paid family leave and paid time off.
  • Financial & Career Growth: Higher education and certification tuition assistance, loan assistance and 401(k) retirement package and company match.
  • Employee Well-being: Mental, physical, and financial wellness programs (free gym memberships, virtual care appointments, mental health services and discount programs).
  • Professional Development: Ongoing learning and career advancement opportunities.

More about Denver Springs Hospital

Denver Springs is located in Englewood, CO, and is part of Lifepoint Health, a diversified healthcare delivery network committed to making communities healthier with acute care, rehabilitation, and behavioral health facilities from coast to coast. From your first day to your next career milestone-your experience matters 

Hourly range

$26-$33 

EEOC Statement

"Denver Springs is an Equal Opportunity Employer. Denver Springs is committed to Equal Employment Opportunity for all applicants and employees and complies with all applicable laws prohibiting discrimination and harassment in employment."

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.We employ and provide care to people from all walks of life. We are committed to promoting healing, providing hope, preserving dignity and producing value with an inclusive workforce in which diversity is leveraged, respected, and reflective of the patients, family members, customers and team members we serve.

What LifePoint Health employees say

Pay

Benefits

Hours and flexibility

Workplace

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About LifePoint Health

Sourced by ZipRecruiter

Lifepoint Health serves patients, clinicians, communities and partners across the healthcare continuum. Our diversified healthcare delivery network extends from coast to coast, consisting of community hospitals, rehabilitation and behavioral health hospitals, and additional sites of care.

Industry

Health care and social assistance

Company size

10,000+ Employees

Headquarters location

Brentwood, TN, US

Year founded

1999

Social media

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