Evaluate medical necessity and appropriateness of hospital admissions and continued stays using evidence-based criteria. Perform reviews, document in case management systems, coordinate with clinicians and payers, support denials and appeals, analyze utilization trends, and assist with process improvements and training to optimize resource use and compliance.
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
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.
- Maintains regular and reliable attendance.
- Complies with all policies and standards.
- 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
- 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.
- RN - Registered Nurse - State Licensure and/or Compact State Licensure required
- CCM - Certified Case Manager preferred or
- Accredited Case Manager (ACM) preferred
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Evaluate medical necessity and appropriateness of hospital services through admission and continued-stay reviews. Document reviews in case management software/EHR, coordinate with physicians and payers for authorizations, support denials and appeals, analyze utilization trends, and collaborate with case managers and discharge planners to optimize resource use and compliance.
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