Utilization Review Specialist

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

📋 Description

• Evaluate and examine 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 informed decisions regarding the authorization, continuation, modification, or denial of services based on clinical guidelines and regulatory standards.

• Keep precise and detailed records of utilization review activities, decisions, and communications in accordance with organizational policies and legal requirements.

• Remain updated on changing healthcare regulations, payer policies, and clinical best practices to guarantee consistent and compliant review processes.

⛳️ Requirements

• Bachelor’s degree in Nursing, Health Administration, or a comparable healthcare field.

• 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.

• Familiarity with insurance authorization processes and healthcare reimbursement models.

• Excellent analytical, communication, and organizational abilities.

• Preferred Qualifications: Registered Nurse (RN) license or equivalent clinical certification.

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

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

• Previous experience working with managed care organizations or insurance companies.

• Advanced understanding of Medicare, Medicaid, and other payer-specific guidelines.

🏝️ Benefits

• Medical Coverage – Three new BCBSAL medical plans with 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) featuring 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 – Offered for nurses and therapists.

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

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

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