PRN Clinical Utilization Review Specialist

Community Health Systems Professional Services Corporation•Franklin, TN

2d•Remote

About The Position

The PRN Remote Clinical Utilization Review Specialist evaluates the necessity, appropriateness, and efficiency of hospital services to ensure compliance with utilization management policies. The role conducts admission and continued stay reviews, supports denials and appeals activities, and collaborates with healthcare providers to facilitate efficient patient care. The specialist monitors adherence to hospital utilization review plans and works to optimize hospital resource utilization, reduce readmissions, and maintain compliance with payer requirements.

Requirements

Technical School in Practical Nursing or an Associate Degree in Nursing.
2–4 years of clinical experience in utilization review, case management, or acute care nursing.
LPN state licensure, or RN state licensure and/or Compact State Licensure.
Strong knowledge of utilization management principles, payer guidelines, and regulatory requirements.
Proficiency in case management software and electronic health records (EHR).
Excellent communication and collaboration skills for working with interdisciplinary teams and external payers.
Strong analytical and problem-solving skills to assess utilization trends and optimize hospital resource use.
Ability to work in a fast-paced environment while maintaining attention to detail and accuracy.
Knowledge of HIPAA regulations and patient confidentiality standards.

Nice To Haves

1–3 years of work experience in care management.
1–2 years of experience in utilization management, payer relations, or hospital revenue cycle.
Certified Case Manager (CCM).
Accredited Case Manager (ACM).

Responsibilities

Perform admission and continued stay reviews using evidence-based criteria, clinical expertise, and regulatory guidelines to ensure appropriate utilization of hospital services.
Collaborate with physicians and clinical teams to obtain necessary documentation for medical necessity, discharge planning, and payer requirements.
Document utilization review activities in the hospital’s case management software, including clinical reviews, escalations, avoidable days, payer communications, and authorization details.
Work with insurance companies to secure coverage approvals and mitigate concurrent denials by submitting reconsiderations or coordinating peer-to-peer reviews.
Communicate with utilization review coordinators, case managers, and discharge planners to support collaborative patient care.
Analyze trends in hospital admissions and extended stays and identify opportunities to improve utilization management processes.
Serve as a key contact for facility staff and insurance representatives regarding utilization review concerns.
Support departmental training initiatives and escalate complex issues to management as needed.
Perform other duties as assigned.
Maintain regular and reliable attendance.
Comply with all policies and standards.