Utilization Review Specialist

Job Overview

As a Utilization Review Specialist, you’ll review clinical records and care plans to support appropriate, well-documented healthcare decisions. You’ll collaborate with clinical and administrative teams, apply utilization management criteria, and help align services with patient needs and applicable regulations.

Responsibilities

• Review medical records, clinical documentation, and proposed services for medical necessity, completeness, and alignment with clinical documentation standards.
• Apply utilization review practices and knowledge of Medicare, managed care, Centers for Medicare and Medicaid Services (CMS) requirements, state healthcare regulations, and Health Insurance Portability and Accountability Act (HIPAA) privacy rules.
• Coordinate with providers and case management teams on documentation gaps, discharge planning, and care transitions across inpatient, outpatient, home care, and long-term care settings.
• Use electronic medical record (EMR) and electronic health record (EHR) systems to document reviews and manage records; systems may include Epic, Cerner, Athenahealth, or eClinicalWorks.
• Your impact: Clear, timely reviews help care teams make informed decisions and support patients in receiving appropriate care.

Experience

• Nursing or related clinical experience, with knowledge of patient care, anatomy, physiology, and medical terminology.
• Experience in utilization management, medical management, documentation review, health information management, or clinical documentation improvement.
• Familiarity with medical coding, including ICD-9, ICD-10, Current Procedural Terminology (CPT), diagnosis-related groups (DRG), and Minimum Data Set (MDS); knowledge of HEDIS and National Committee for Quality Assurance (NCQA) standards is useful.
• Experience in hospital, acute care, critical care, intensive care unit (ICU), emergency medicine, primary care, clinic, medical office, nursing home, hospice, or long-term care settings is relevant. Pediatric, PICU, trauma center, and discharge planning experience are also valued.
• Microsoft Office skills and knowledge of Medicare regulations, long-term care regulations, and clinical documentation standards are preferred.

Pay: $16.00 - $20.00 per hour

Expected hours: 40.0 per week

Benefits:

• 401(k)
• Health insurance
• Paid time off

Work Location: In person