Utilization Review Specialist

Job Title: Utilization Review Specialist Pay Range: $27.74 - $41.61 per day Reports to: Manager - Utilization Management Department: Utilization Management Position Overview The Utilization Review Specialist works under the direction of the Utilization Management Manager and serves as an interdisciplinary team member within the Utilization Management Department. Responsibilities include verification of benefits, authorization procurement, and collaboration with physicians, case managers, social workers, patient access, billing, and other departments to avoid delays in patient care and billing. The role serves as the first point of escalation for payors requiring additional information to support authorization and ensures timely procurement of authorization upon admission, discharge, and accuracy of authorization information. Essential Functions and Duties Act as interdisciplinary team member within the Utilization Management department. Accurately complete assigned requests submitted from payors; promptly escalates cases requiring clinical expertise to UM RN and/or multidisciplinary team. Escalate medical necessity concerns and other UM concerns to the Physician Advisor. Submit clinical reviews and information supporting admission, continued stay reviews, and discharge information to payors. Identify and escalates all 1MN Medicare and 2MN Observation stays for review at committee through use of assigned work queues. Review and address all discharged encounters pending payor authorization follow‑up. Maintain a working knowledge of UM specific changes and regulatory requirements. Prepare and facilitate delivery of regulatory notices and ensure compliance with payor regulations. Support clinical denials and appeals processes, both concurrent and post‑claim. Support peer‑to‑peer workflows and the discharge appeal process. Collaborate with Case Management and Social Work teams on extended observation stays and status changes. Communicate and collaborate with Patient Access, Patient Financial Services, and Health Information Management. Provide timely and continual coverage of assigned work area to ensure all accounts are complete. Document all interactions with patients, families, and care team members. Follow up on action items prior to the end of shift and complete all tasks within department guidelines. Adhere to policies, procedures, rules, regulations, and laws of the hospital and governing bodies. Assist Department Manager with quality audits and participate in tracking of departmental quality measures. Support the organization’s vision, mission, values, and continuous improvement initiatives. Provide and maintain a safe environment for caregivers, patients, and guests. Act with professionalism, confidentiality, and ethical conduct. Deliver customer service and patient care in a timely, efficient, and accurate manner. May perform additional duties of similar complexity as required. Education Associate degree or higher in Health Information Management. Licensure / Certification Current RHIT required. Experience Required: 1 year in a similar hospital‑related position in Health Information Management. Personal Protective Equipment Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely. Additional Position Information Excellent communication skills and ability to interact with a diverse population. Ability to interact and communicate with all levels within the organization and external clients. Strong teamwork, collaborative skills, and ability to multi‑task and work independently. Attention to detail, excellent organizational, written and oral communication, and customer service skills. Strong analytical, problem‑solving, and decision‑making skills. Intermediate to advanced proficiency in Microsoft Word, Excel, Access, database management, and document preparation. Physical Requirements Continually (≥75%): Clear and audible speaking voice, ability to hear normal speech level. Frequently (≈50%): Sitting, standing, walking, lifting 1–10 pounds, keyboard operation. Occasionally (≈25%): Bending, climbing stairs, reaching overhead, carrying/pushing or pulling 1–10 pounds. Rarely (≈10%): Stooping/kneeling/crouching, lifting 11–15 pounds, operating a motor vehicle. Never (0%): Climbing ladder/step‑stool, lifting 25–50 pounds, hearing whispered speech level. Exposure to elemental factors: never. Blood‑borne pathogen exposure: no risk. Schedule and Shift Weekly hours: 0 (relief). Shift: First Shift (United States of America); start 8:00, end 16:30. Scheduled days of the week: As scheduled (may include weekends and holidays). #J-18808-Ljbffr