Utilization Review Clinical Specialist (Full-TimeTowson)

What to expect

• The Utilization Review Clinical Specialist provides timely comprehensive utilization reviews for behavioral health services for Sheppard Pratt patients. Collaborating closely with the Utilization Review team and an interdisciplinary clinical team the specialist conducts medical reviews for inpatient and partial hospitalization programs maintains accurate documentation within hospital data systems and communicates effectively with internal stakeholders and external agencies. The role also involves coordinating with Medicare Medicaid and Commercial Health Plans to ensure compliance with CMS (Centers for Medicare & Medicaid Services) Maryland Medicaid and payer-specific requirements. The UR Clinical Specialist leads the appeals process through data-driven analysis optimized workflows and strengthened clinical documentation to support medical necessity decisions and successful appeal outcomes.

Whatyoullget from us

At Sheppard Pratt you will work alongside a multi-disciplined team led by a bold vision to change lives. We offer:

• A commitment to professional development including a comprehensive tuition reimbursement program to support ongoing education and licensure and/or certification preparation

• Comprehensive medical dental and vision benefits forbenefiteligible positions

• 403b retirement match

• Generous paid-time-off forbenefiteligible positions

• Complimentary Employee Assistance Program (EAP)

• Generous mileage reimbursement program

Pay for this position is determined on a number of factors including but not limited to years and level of related experience.

What we need from you

• Associate or Bachelorsdegree in nursingBachelors ORMastersdegree inClinical CounselingHealthcare Administration or related clinical field.
• Active RN license orLicensed Clinical Professional Counselor(LCPC)
• Minimum of 3-5 years of experience inutilizationrevieworbehavioral health.
• Strong knowledge of payer requirements clinicalcriteriaand behavioral health diagnosis.
• Attend patient focused roundsin order topresent concrete and expert clinical knowledge on behalf of the patient and the health plans.
• Strong communicationskills that allowfor patient advocacyrelated tocontinued stay and discharge needs.
• Essentialcomputer skillswhichfocus on EHR/EMR systems data managementalongside core office skills like Microsoft Office (Excel Word)

WHY SHEPPARD PRATT

At Sheppard Pratt we are more than just a workplace. We are a community of healthcare professionals who are dedicated to providing hope and healing toindividualsfacinglifeschallenges. Join us and be a part of a mission that changes lives!

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Required Experience:

IC