Utilization Review Specialist
About The Position
The Utilization Review Specialist evaluates healthcare services to determine whether they are medically necessary, efficient, and compliant with regulatory standards. The role involves reviewing patient records, treatment plans, and clinical data, and collaborating with healthcare providers, insurance companies, and case managers to facilitate timely approvals and support patient outcomes. The specialist applies clinical knowledge and regulatory guidelines to help manage healthcare costs while maintaining quality of care. The role also requires accurate documentation of utilization review activities and decisions, and staying current with healthcare regulations, payer policies, and clinical best practices.
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.
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 and detailed records of utilization review activities, decisions, and communications in compliance with organizational policies and legal standards.
- Stay current with evolving healthcare regulations, payer policies, and clinical best practices to ensure consistent and compliant review processes.
Benefits
- Medical coverage with three BCBSAL medical plans.
- 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 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) 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.
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
