Utilization Management Clinical Specialist
Sheppard Pratt
What to expect:
Pay for this position is determined on a number of factors, including but not limited to, years and level of related experience.
What we need from You:
#LI-SM1 Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.
For further information, please review the Know Your Rights notice from the Department of Labor.
- Provides timely, comprehensive utilization reviews for behavioral health services for Sheppard Pratt patients.
- Conducts medical reviews for inpatient and partial hospitalization programs, maintains accurate documentation within hospital data systems, and communicates effectively with internal stakeholders and external agencies.
- Coordinates with Medicare, Medicaid, and Commercial Health Plans to ensure compliance with CMS (Centers for Medicare & Medicaid Services), Maryland Medicaid, and payer-specific requirements.
- Leads the appeals process through data-driven analysis, optimized workflows, and strengthened clinical documentation to support medical necessity decisions and successful appeal outcomes.
- A commitment to professional development, including a comprehensive tuition reimbursement program to support ongoing education and licensure and/or certification preparation
- Comprehensive medical, dental and vision benefits for benefit eligible positions
- 403b retirement match
- Generous paid-time-off for benefit eligible positions
- Complimentary Employee Assistance Program (EAP)
- Generous mileage reimbursement program
Pay for this position is determined on a number of factors, including but not limited to, years and level of related experience.
What we need from You:
- Associate or Bachelor’s degree in nursing, Bachelor’s or Master’s degree in Clinical Counseling, Healthcare Administration, or related clinical field.
- Active RN license, Licensed Clinical Professional Counselor (LCPC), or Licensed Certified Social Worker-Clinical (LCSW-C).
- Minimum of 3-5 years of experience in utilization management, or behavioral health.
- Strong knowledge of payer requirements, clinical criteria and behavioral health diagnosis.
#LI-SM1 Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.
For further information, please review the Know Your Rights notice from the Department of Labor.
Vacancy posted 3 days ago
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