Senior Utilization Review Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct concurrent and retrospective utilization reviews for designated inpatient, observation, and outpatient cases.

• Utilize InterQual, MCG, or client-sanctioned criteria to validate medical necessity, level of care, continued stay, and patient-status assessments.

• Acquire, submit, and monitor payer notifications and authorizations.

• Relay clinically significant information to payer medical-management teams within stipulated time frames.

• Recognize and escalate issues related to medical necessity, authorizations, status, and documentation risks.

• Collaborate with physicians, case management, CDI, coding, patient access, and revenue cycle stakeholders.

• Organize clinical information and timelines for peer-to-peer reviews or denial escalations.

• Ensure thorough and precise documentation is maintained in designated systems.

• Participate in the Utilization Review Committee and generate reports on utilization trends, denial patterns, extended stays, and workflow obstacles.

• Bring patient-status-change compliance issues to the attention of UR Committee members and present findings.

• Offer guidance and support on complex review inquiries as a senior clinical expert.

• Engage in quality audits, educational initiatives, process improvement, and utilization management efforts.

⛳️ Requirements

• Valid, unrestricted RN license.

• A minimum of five years of experience in acute-care hospital settings.

• At least three years of experience in utilization review, utilization management, case management, or a closely related area.

• Proven experience in applying medical necessity and level of care criteria, including concurrent and continued stay reviews.

• Proficient understanding of inpatient versus observation status, payer authorization requirements, Medicare and managed-care utilization principles, and practices to prevent denials.

• Excellent clinical judgment, prioritization, documentation, communication, and collaborative problem-solving abilities.

• Capability to independently manage a high-volume, deadline-oriented caseload while exercising sound judgment regarding necessary escalations.

• Availability during agreed-upon hospital business hours.

• Maintain discretion with protected health information and ensure strict adherence to HIPAA, client security standards, and relevant regulations.

🏝️ Benefits

• Part-time employment.

• Fully remote work setup.

• Involvement in mandatory meetings and educational opportunities.

• Engagement in process improvement and professional development initiatives.