Utilization Reviewer
Utilization Reviewer
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1 Vacancy
Job Description
Job Summary:
The Utilization Reviewer is responsible for reviewing medical services and treatment plans to ensure they are medically necessary appropriate and in compliance with payer guidelines and regulatory requirements. This role helps optimize the use of healthcare resources by evaluating clinical documentation against established criteria.
Key Responsibilities:
Review clinical documentation to determine medical necessity for proposed treatments procedures or hospital admissions.
Apply evidence-based guidelines (e.g. MCG InterQual) and payer-specific criteria in review processes.
Coordinate with physicians nurses and other healthcare professionals to obtain necessary information for case review.
Make timely decisions on authorization requests and communicate determinations clearly and professionally.
Prepare and document clinical reviews and decisions accurately in the utilization review system.
Participate in appeals processes by preparing detailed case summaries and collaborating with medical directors.
Monitor patient progress and ongoing need for care through concurrent and retrospective review.
Maintain up-to-date knowledge of clinical guidelines regulatory changes and insurance policies.
Ensure compliance with federal state and accreditation standards (e.g. CMS NCQA URAC).
Provide utilization data and trends to help improve patient care and resource management.
Qualifications:
Education & Licensure:
RN LPN or other licensed clinical professional (depending on organization)
Active unencumbered license in the state of practice
Utilization Review certification (e.g. CPHQ CM CCM) preferred
Experience:
25 years of clinical experience in a healthcare setting
13 years of experience in utilization management case management or quality assurance preferred
Skills:
Strong understanding of medical terminology treatment protocols and insurance requirements
Proficient in using utilization review software and electronic health records (EHRs)
Excellent analytical communication and decision-making skills
Ability to work independently and meet strict deadlines
Employment Type
Full Time
