Utilization Review Specialist (FLEXI)

Summary

The Utilization Review Specialist supports the organization’s utilization management program by conducting routine admission, concurrent, and retrospective reviews utilizing established screening criteria and organizational guidelines. This position collects, reviews, and documents clinical information to support medical necessity determinations and appropriate resource utilization. Complex, high-risk, or ambiguous cases requiring clinical judgment are referred to a RN Utilization Review for review and determination.

Essential Duties and Responsibilities

These duties and responsibilities described below represent the general tasks performed on a daily basis; other tasks may be assigned.

• Conduct routine utilization reviews using approved screening criteria, established workflows, and departmental guidelines.

• Collect and organize clinical documentation necessary to support utilization review activities.

• Review patient records to identify required information for admission, continued stay, and discharge planning processes.

• Apply established criteria to routine cases and document findings in designated systems.

• Monitor assigned cases for required documentation and timely review completion.

• Communicate with providers, clinical staff, payers, and care team members to obtain necessary information.

• Identify cases that do not clearly meet established criteria and escalate them to an RN Utilization Review.

• Present complex, high-acuity, disputed, or clinically ambiguous cases to an RN Utilization Review Specialist for evaluation and determination.

• Assist with obtaining payer authorizations and tracking authorization status as directed.

• Maintain accurate utilization management records, reports, and audit documentation.

• Support denial prevention efforts through timely documentation and communication.

• Participate in quality improvement initiatives related to utilization management processes.

• Maintain knowledge of applicable payer requirements, regulatory standards, and organizational policies.

• Assist with data collection and reporting related to utilization management metrics.

• Perform other utilization management support duties within the scope of licensure and training.

Supervisory Responsibilities

Reports to: RN Clinical Doc Manager

Supervises: N/A

Responsibilities: N/A

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and Experience

Minimum Required Education

Graduate of an approved healthcare program leading to licensure as a healthcare professional i.e. Licensed Practical Nurse (LPN) or other clinically licensed healthcare professionals as approved by the organization.

Experience

Two (2) years of clinical healthcare experience required. Experience in utilization review, utilization management, case management, care coordination, discharge planning, or other related clinical healthcare functions may be considered.

Certificates, Licenses, Registrations

• Current unrestricted license as a Licensed Practical Nurse required at minimum in the Commonwealth of Virginia or compact state. Candidates possessing a higher level of clinical licensure are also eligible for consideration.

• Certification in utilization management or case management preferred.