Utilization Review Specialist
About The Position
As a Utilization Review Specialist, you will play a pivotal role in ensuring the efficient and effective utilization of healthcare resources. You will be responsible for reviewing and evaluating clinical documentation, treatment plans, and medical records to optimize patient care and streamline healthcare delivery processes. The principal functions of the position identified shall not be considered as a complete description of all the work requirements and expectations that may be inherent in the position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position.
Requirements
- Bachelor's degree in a healthcare-related field (Social Work, Mental Health Counseling, Physical Therapy, Occupational Therapy, Speech-Language Pathology, Nursing); Master's degree preferred.
- Relevant clinical licensure or certification (e.g., BCBA, LSW, LMHC, PT, OT, SLP, RN).
- Proven experience in utilization review or a related field with a strong understanding of healthcare service delivery and documentation processes is highly desirable.
- Up-to-date knowledge of relevant healthcare regulations, guidelines, and accreditation standards.
- Understanding of compliance requirements and the ability to ensure adherence during the utilization review process.
- Must maintain clean background/drug screenings and driving record
- Familiarity with industry standards, guidelines, and best practices related to utilization review.
- Ability to analyze complex clinical documentation, treatment plans, and medical records.
- Strong critical thinking skills to assess the appropriateness and necessity of healthcare services.
- Strong analytical and critical thinking skills.
- Excellent communication and interpersonal skills.
- Ability to work collaboratively in a team-oriented environment.
Responsibilities
- Clinical Documentation Review:
- Evaluate and analyze medical records, treatment plans, and clinical documentation to ensure accuracy and compliance with established standards.
- Collaborate with healthcare providers to gather additional information or clarification on documentation when necessary.
- Utilization Review:
- Assess the appropriateness and necessity of healthcare services, ensuring they align with established guidelines and policies.
- Identify and communicate potential issues related to overutilization or underutilization of services.
- Collaboration and Communication:
- Work closely with interdisciplinary teams, Board Certified Behavior Analysts, Registered Behavior Technicians, and other healthcare professionals to gather insights and ensure comprehensive reviews.
- Communicate findings and recommendations clearly and effectively to internal teams and external stakeholders.
- Quality Improvement:
- Participate in quality-improvement initiatives to enhance the overall efficiency and effectiveness of healthcare delivery.
- Provide feedback and suggestions for process improvements based on review findings.
- Regulatory Compliance:
- Stay informed on relevant healthcare regulations, guidelines, and accreditation standards.
- Ensure compliance with all applicable laws and regulations in the utilization review process.
Benefits
- 21 paid days off (15 days of PTO, which increases with tenure, plus 6 holidays).
- Flexible Spending Account (FSA) and Health Savings Account (HSA) options.
- Medical, dental, vision, long-term disability, and life insurance.
- Generous 401(k) with up to 6% employer match.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
