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 to assess the appropriateness of care and resource use. It collaborates with healthcare providers, insurance companies, and case managers to facilitate timely approvals and support patient outcomes. Applying clinical knowledge and regulatory guidelines, the specialist helps control healthcare costs while maintaining quality care and contributing to the integrity and sustainability of healthcare delivery systems across the United States.
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.
- Ability to manage multiple cases, maintain detailed documentation, and meet deadlines.
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 healthcare regulations, payer policies, and clinical best practices to ensure consistent and compliant review processes.
Benefits
- Medical coverage, including 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 with digital wellness tools, Cognitive Behavioral Therapy modules, and wellness coaching.
- Voluntary coverages, including pet insurance, home and auto insurance, and family legal services.
- Student loan repayment for nurses and therapists.
- 401(k) plan through Voya.
- Generous paid time off.
- Voluntary benefits for part-time employees working 20 or more hours per week, including dental, vision, life, accident insurance, and telehealth options.
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What This Job Offers
Job Type
Full-time
