Utilization Management Clinical Specialist

Sheppard Pratt • Towson, MD

2d • $68,000 - $108,577

About The Position

Provides timely, comprehensive utilization reviews for behavioral health services for Sheppard Pratt patients. Conducts medical reviews for inpatient and partial hospitalization programs, maintains accurate documentation within hospital data systems, and communicates effectively with internal stakeholders and external agencies. Coordinates with Medicare, Medicaid, and Commercial Health Plans to ensure compliance with CMS (Centers for Medicare & Medicaid Services), Maryland Medicaid, and payer-specific requirements. Leads the appeals process through data-driven analysis, optimized workflows, and strengthened clinical documentation to support medical necessity decisions and successful appeal outcomes.

Requirements

• Associate or Bachelor’s degree in nursing, Bachelor’s or Master’s degree in Clinical Counseling, Healthcare Administration, or related clinical field.
• Active RN license, Licensed Clinical Professional Counselor (LCPC), or Licensed Certified Social Worker-Clinical (LCSW-C).
• Minimum of 3-5 years of experience in utilization management, or behavioral health.
• Strong knowledge of payer requirements, clinical criteria and behavioral health diagnosis.

Responsibilities

• Provides timely, comprehensive utilization reviews for behavioral health services for Sheppard Pratt patients.
• Conducts medical reviews for inpatient and partial hospitalization programs.
• Maintains accurate documentation within hospital data systems.
• Communicates effectively with internal stakeholders and external agencies.
• Coordinates with Medicare, Medicaid, and Commercial Health Plans to ensure compliance with CMS (Centers for Medicare & Medicaid Services), Maryland Medicaid, and payer-specific requirements.
• Leads the appeals process through data-driven analysis, optimized workflows, and strengthened clinical documentation to support medical necessity decisions and successful appeal outcomes.

Benefits

• A commitment to professional development, including a comprehensive tuition reimbursement program to support ongoing education and licensure and/or certification preparation
• Comprehensive medical, dental and vision benefits for benefit eligible positions
• 403b retirement match
• Generous paid-time-off for benefit eligible positions
• Complimentary Employee Assistance Program (EAP)
• Generous mileage reimbursement program

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree