Evaluate medical necessity and appropriateness of admissions and continued stays, conduct reviews using evidence-based criteria, coordinate with providers and payers for authorizations and appeals, document activity in case management/EHR, analyze utilization trends, support training, and escalate complex issues.
Job Summary
The Clinical Utilization Review Specialist is responsible for evaluating the necessity, appropriateness, and efficiency of healthcare services for assigned patient populations to ensure compliance with utilization management policies. This role conducts admission and continued stay reviews, supports denials and appeals activities, and collaborates with healthcare providers to facilitate efficient patient care. The Clinical Utilization Review Specialist monitors adherence to hospital utilization review plans and works to optimize resource utilization, reduce readmissions, and maintain compliance with payer requirements.
Essential Functions
The Clinical Utilization Review Specialist is responsible for evaluating the necessity, appropriateness, and efficiency of healthcare services for assigned patient populations to ensure compliance with utilization management policies. This role conducts admission and continued stay reviews, supports denials and appeals activities, and collaborates with healthcare providers to facilitate efficient patient care. The Clinical Utilization Review Specialist monitors adherence to hospital utilization review plans and works to optimize resource utilization, reduce readmissions, and maintain compliance with payer requirements.
Essential Functions
- Performs admission and continued stay reviews using evidence-based criteria, clinical expertise, and regulatory guidelines to ensure appropriate utilization of services for assigned patient populations.
- Collaborates with physicians, behavioral health providers, and/or interdisciplinary clinical teams to obtain necessary documentation for medical necessity, discharge planning, and payer requirements.
- Documents all utilization review activities in the hospital’s case management software, including clinical reviews, escalations, avoidable days, payer communications, and authorization details.
- Works with insurance companies to secure coverage approvals and mitigate concurrent denials by submitting reconsiderations or coordinating peer-to-peer reviews.
- Communicates effectively with utilization review coordinators, case managers, and discharge planners to ensure a collaborative approach to patient care.
- Analyzes trends in utilization, authorization activity, denials, and extended stays to identify opportunities for process improvements that enhance utilization management.
- Serves as a key contact for facility staff and insurance representatives regarding utilization review concerns.
- Supports training initiatives within the department and escalates complex issues to management as needed.
- Performs other duties as assigned.
- Maintains regular and reliable attendance.
- Complies with all policies and standards.
- Associate Degree or higher in Nursing required or
- Master's Degree in Social Work required
- 2-4 years of clinical experience in utilization review, case management, care management, behavioral health, or acute care required
- 1-3 years work experience in care management preferred
- 1-2 years of experience in utilization management, payer relations, denials and appeals, or hospital revenue cycle preferred
- Strong knowledge of utilization management principles, medical necessity criteria, payer guidelines, and regulatory requirements applicable to assigned patient populations.
- Proficiency in case management software and electronic health records (EHR).
- Excellent communication and collaboration skills to work effectively with interdisciplinary teams and external payers.
- Strong analytical and problem-solving skills to assess utilization trends and optimize hospital resource use.
- Ability to work in a fast-paced environment while maintaining attention to detail and accuracy.
- Knowledge of HIPAA regulations and patient confidentiality standards.
- RN - Registered Nurse - State Licensure and/or Compact State Licensure required or
- LCSW- License Clinical Social Worker required
- CCM - Certified Case Manager preferred or
- Accredited Case Manager (ACM) preferred
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