Utilization Review Specialist
About The Position
The Utilization Review Specialist evaluates healthcare services to ensure they are medically necessary, efficient, and compliant with regulatory standards. The role reviews patient records, treatment plans, and clinical data, and collaborates with healthcare providers, insurance companies, and case managers to facilitate timely approvals and optimize patient outcomes. Applying clinical knowledge and regulatory guidelines, the specialist helps control healthcare costs while maintaining high-quality care. The specialist uses clinical expertise and analytical skills to assess care plans against medical criteria and payer policies. The role requires effective communication with multidisciplinary teams, strong organization to manage multiple cases and deadlines, proficiency with healthcare IT systems, and adaptability to evolving regulations and clinical standards.
Requirements
- Bachelor’s degree in a healthcare or related field.
- At least 2 years of experience in utilization review, case management, or clinical healthcare roles.
- Strong knowledge of medical terminology, clinical procedures, and healthcare regulations.
- Familiarity with insurance authorization processes and healthcare reimbursement models.
- Excellent analytical, communication, and organizational skills.
- Proficiency with healthcare IT systems to retrieve data and document utilization review activities.
Nice To Haves
- Experience with electronic health records (EHR) systems and utilization management software.
- Certification in Utilization Review, such as Certified Professional in Utilization Review or Certified Case Manager.
- Prior experience working with managed care organizations or insurance companies.
- Advanced knowledge of Medicare, Medicaid, and other payer-specific guidelines.
Responsibilities
- Review and analyze medical records, treatment plans, and clinical documentation to assess the necessity and appropriateness of healthcare services.
- Coordinate with healthcare providers, insurance representatives, and case managers to obtain additional information and clarify treatment details.
- Make decisions regarding authorization, continuation, modification, or denial of services based on clinical guidelines and regulatory requirements.
- Maintain accurate, detailed records of utilization review activities, decisions, and communications in compliance with organizational policies and legal standards.
- Stay current with healthcare regulations, payer policies, and clinical best practices to ensure consistent, compliant review processes.
Benefits
- Medical coverage through three BCBSAL medical plans, with improved rates, co-pays, and prescription benefits.
- Expanded coverage options for domestic partners and a wider network of in-network providers.
- Mental health support, including an Employee Assistance Program (EAP) with digital wellness tools such as CBT modules and wellness coaching.
- Voluntary coverages including pet insurance, home and auto insurance, and family legal services.
- Student loan repayment available for nurses and therapists.
- 401(k) retirement plan through Voya.
- Generous paid time off.
- Voluntary dental, vision, life, accident insurance, and telehealth options for part-time employees working 20 hours or more per week.
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What This Job Offers
Job Type
Full-time
