Utilization Review Specialist

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

📋 Description

• Conduct thorough reviews and analyses of medical records, treatment plans, and clinical documentation to determine the necessity and appropriateness of healthcare services.

• Collaborate with healthcare providers, insurance representatives, and case managers to gather additional information and clarify treatment specifics.

• Make well-informed decisions regarding the authorization, continuation, modification, or denial of services in accordance with clinical guidelines and regulatory standards.

• Maintain precise and comprehensive records of utilization review activities, decisions, and communications, ensuring compliance with organizational policies and legal requirements.

• Keep abreast of changing healthcare regulations, payer policies, and clinical best practices to guarantee consistent and compliant review processes.

⛳️ Requirements

• A Bachelor’s degree in Nursing, Health Administration, or a related healthcare discipline.

• A minimum of 2 years of experience in utilization review, case management, or clinical healthcare positions.

• Strong understanding of medical terminology, clinical procedures, and healthcare regulations.

• Knowledge of insurance authorization processes and healthcare reimbursement models.

• Exceptional analytical, communication, and organizational abilities.

• Registered Nurse (RN) license or equivalent clinical certification is preferred.

• Experience with electronic health records (EHR) systems and utilization management software is preferred.

• Certification in Utilization Review (e.g., Certified Professional in Utilization Review or Certified Case Manager) is preferred.

• Advanced knowledge of Medicare, Medicaid, and other payer-specific guidelines is preferred.

🏝️ Benefits

• Medical Coverage – Three new BCBSAL medical plans featuring improved rates, better co-pays, and enhanced prescription benefits.

• Expanded Coverage – Options available for domestic partners and a broader network of in-network providers.

• Mental Health Support – Enhanced access to services and a new Employee Assistance Program (EAP) offering digital wellness tools such as Cognitive Behavioral Therapy (CBT) modules and wellness coaching.

• Voluntary Coverages – Options for pet insurance, home and auto insurance, family legal services, and more.

• Student Loan Repayment – Available for nurses and therapists.

• Retirement Benefits – A 401(k) plan through Voya to assist employees in planning for their future.

• Generous PTO – A comprehensive paid time off policy designed to foster work-life balance.

• Voluntary Benefits for Part-Time Employees – Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week.