We are seeking a highly motivated and detail-oriented Utilization Reviewer to join our dynamic healthcare team. In this pivotal role, you will evaluate medical records, clinical documentation, and patient care plans to ensure appropriate utilization of healthcare services. Your expertise will support clinical decision-making, promote compliance with regulatory standards, and optimize patient outcomes. The ideal candidate will possess a strong foundation in medical terminology, coding, and utilization management processes, with a passion for improving healthcare efficiency and quality.
Review medical documentation, including clinical notes, discharge summaries, and treatment plans to assess medical necessity and appropriateness of services.
Utilize advanced electronic health record (EHR) systems such as Epic, Cerner, Athenahealth, or eClinicalWorks to access and analyze patient information efficiently.
Apply knowledge of CPT coding, ICD-9/10 coding systems, DRGs (Diagnosis-Related Groups), and MDS (Minimum Data Set) to accurately classify diagnoses and procedures.
Conduct utilization reviews for inpatient and outpatient services across various settings including acute care hospitals, nursing homes, hospice care, emergency departments, PICUs (Pediatric Intensive Care Units), and Level I/II trauma centers.
Collaborate with multidisciplinary teams to facilitate discharge planning, case management, and clinical documentation improvement initiatives aligned with NCQA standards.
Ensure compliance with HIPAA regulations while handling sensitive patient information and medical records.
Participate in ongoing education related to managed care policies, Medicare/Medicaid guidelines, and evolving healthcare regulations to maintain current knowledge.
Proven experience in utilization review or utilization management within hospital or managed care environments.
Strong background in clinical settings such as ICU, emergency medicine, primary care, pediatrics, or nursing homes.
Familiarity with EMR/EHR systems like Epic, Cerner, Athenahealth or eClinicalWorks is essential for efficient workflow.
In-depth understanding of medical coding including CPT, ICD-9/10 codes, DRGs, and case management documentation standards.
Critical care experience or ICU background is highly desirable for assessing complex cases accurately.
Knowledge of Medicare regulations and NCQA standards to ensure compliance during reviews.
Excellent analytical skills combined with a thorough understanding of anatomy physiology and medical terminology to interpret complex clinical data effectively. Join us in making a meaningful impact on patient care by ensuring the appropriate use of healthcare resources! We are committed to fostering an inclusive environment that supports your professional growth while promoting work-life balance through comprehensive benefits designed to support your overall well-being.
