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Job Summary

The Clinical Utilization Review Specialist is responsible for evaluating the necessity, appropriateness, and efficiency of hospital services to ensure compliance with utilization management policies. This role conducts admission and continued stay reviews, supports denials and appeals activities, and collaborates with healthcare providers to facilitate efficient patient care. The Clinical Utilization Review Specialist monitors adherence to hospital utilization review plans and works to optimize hospital resource utilization, reduce readmissions, and maintain compliance with payer requirements.

Essential Functions

+ Performs admission and continued stay reviews using evidence-based criteria, clinical expertise, and regulatory guidelines to ensure appropriate utilization of hospital services.

+ Collaborates with physicians and clinical teams to obtain necessary documentation for medical necessity, discharge planning, and payer requirements.

+ Documents all utilization review activities in the hospital’s case management software, including clinical reviews, escalations, avoidable days, payer communications, and authorization details.

+ Works with insurance companies to secure coverage approvals and mitigate concurrent denials by submitting reconsiderations or coordinating peer-to-peer reviews.

+ Communicates effectively with utilization review coordinators, case managers, and discharge planners to ensure a collaborative approach to patient care.

+ Analyzes trends in hospital admissions and extended stays, identifying opportunities for process improvements to enhance utilization management.

+ Serves as a key contact for facility staff and insurance representatives regarding utilization review concerns.

+ Supports training initiatives within the department and escalates complex issues to management as needed.

+ Performs other duties as assigned.

+ Complies with all policies and standards.

Qualifications

+ Associate Degree in Nursing required

+ Bachelor's Degree in Nursing preferred

+ 2-4 years of clinical experience in utilization review, case management, or acute care nursing required

+ 1-3 years work experience in care management preferred

+ 1-2 years of experience in utilization management, payer relations, or hospital revenue cycle preferred

Knowledge, Skills and Abilities

+ Strong knowledge of utilization management principles, payer guidelines, and regulatory requirements.

+ Proficiency in case management software and electronic health records (EHR).

+ Excellent communication and collaboration skills to work effectively with interdisciplinary teams and external payers.

+ Strong analytical and problem-solving skills to assess utilization trends and optimize hospital resource use.

+ Ability to work in a fast-paced environment while maintaining attention to detail and accuracy.

+ Knowledge of HIPAA regulations and patient confidentiality standards.

Licenses and Certifications

+ RN - Registered Nurse - State Licensure and/or Compact State Licensure required

+ CCM - Certified Case Manager preferred or

+ Accredited Case Manager (ACM) preferred

Equal Employment Opportunity

This organization does not discriminate in any way to deprive any person of employment opportunities or otherwise adversely affect the status of any employee because of race, color, religion, sex, sexual orientation, genetic information, gender identity, national origin, age, disability, citizenship, veteran status, or military or uniformed services, in accordance with all applicable governmental laws and regulations. In addition, the facility complies with all applicable federal, state and local laws governing nondiscrimination in employment. This applies to all terms and conditions of employment including, but not limited to: hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. If you are an applicant with a mental or physical disability who needs a reasonable accommodation for any part of the application or hiring process, contact the director of Human Resources at the facility to which you are seeking employment; Simply go to http://www.chs.net/serving-communities/locations/ to obtain the main telephone number of the facility and ask for Human Resources.