Utilization Review Specialist

LCMC Health•New Orleans, LA

23h•Onsite

About The Position

Supports LCMC Health's mission of delivering exceptional patient care by ensuring the appropriate utilization of healthcare services through timely and accurate medical necessity reviews. Serves as a collaborative liaison between physicians, hospital departments, physician advisors, and third-party payers to facilitate appropriate patient status determinations and authorization processes. Performs pre-certification, concurrent, discharge, retrospective, and appeal reviews, including peer reviews and eligibility verification when appropriate. Applies standardized clinical criteria and regulatory guidelines to determine the appropriate level of care and patient classification, including inpatient, observation, and outpatient status. Maintains compliance with Medicare, Medicaid, and other payer requirements while supporting accurate reimbursement and regulatory standards. Partners with physicians, care management, revenue cycle, and billing teams to promote timely communication, reduce reimbursement delays, and support a seamless patient experience. Identifies potential barriers to payment eligibility or medical necessity and works collaboratively with interdisciplinary teams to resolve issues and recommend appropriate corrective actions. Maintains accurate and timely documentation of utilization review activities in accordance with organizational policies, accreditation standards, and regulatory requirements. Demonstrates a commitment to quality, service excellence, accountability, and continuous improvement while fostering positive working relationships across the organization. Protects patient confidentiality and complies with all applicable HIPAA, organizational, and regulatory requirements.

Requirements

2 years Utilization review/clinical
Bachelor's Degree

Responsibilities

Supports LCMC Health's mission of delivering exceptional patient care by ensuring the appropriate utilization of healthcare services through timely and accurate medical necessity reviews.
Serves as a collaborative liaison between physicians, hospital departments, physician advisors, and third-party payers to facilitate appropriate patient status determinations and authorization processes.
Performs pre-certification, concurrent, discharge, retrospective, and appeal reviews, including peer reviews and eligibility verification when appropriate.
Applies standardized clinical criteria and regulatory guidelines to determine the appropriate level of care and patient classification, including inpatient, observation, and outpatient status.
Maintains compliance with Medicare, Medicaid, and other payer requirements while supporting accurate reimbursement and regulatory standards.
Partners with physicians, care management, revenue cycle, and billing teams to promote timely communication, reduce reimbursement delays, and support a seamless patient experience.
Identifies potential barriers to payment eligibility or medical necessity and works collaboratively with interdisciplinary teams to resolve issues and recommend appropriate corrective actions.
Maintains accurate and timely documentation of utilization review activities in accordance with organizational policies, accreditation standards, and regulatory requirements.
Demonstrates a commitment to quality, service excellence, accountability, and continuous improvement while fostering positive working relationships across the organization.
Protects patient confidentiality and complies with all applicable HIPAA, organizational, and regulatory requirements.