Job Summary:
We are seeking a detail-oriented Utilization Review Specialist to join our healthcare team. The ideal candidate will play a critical role in ensuring that services provided to clients are medically necessary, appropriately documented, and reimbursable by insurance. This position bridges clinical care and billing, ensuring that services are both effective for the client and financially viable for the facility. This is an in-person, Full-time role.
Key Responsibilities:
- Medical Necessity Review: Ensure all treatment services meet the medical necessity criteria set by insurance providers, reducing the risk of claim denials.
- Preauthorization & Concurrent Reviews: Obtain preauthorizations for services when required and conduct ongoing reviews to justify continued treatment.
- Documentation & Compliance: Ensure clinical documentation aligns with payer requirements to support claims, preventing delays or denials.
- Claims Support: Assist billing teams with denials and appeals by providing clinical justification for services rendered.
- Cost Containment: Help maximize reimbursement and minimize financial loss by ensuring all billable services are justified and covered.
Qualifications:
- Proven experience (2+ years) in Utilization Review, Case Management, or a similar healthcare-related role.
- Strong understanding of healthcare regulations, payer policies, and clinical guidelines.
- Ability to communicate complex medical information clearly to healthcare providers, patients, and insurance companies.
- Proficient in using electronic health records (EHR) and other healthcare management software.
- Strong attention to detail, problem-solving, and organizational skills.
Job Type: Full-time
Pay: $25.00 - $32.00 per hour
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Health insurance
- Paid time off
- Vision insurance
Work Location: In person
