UR Clinical Associate

Utilization Review Clinical Associate

This position reports to the Director of Research Innovation. Works closely with and directly supports the Utilization Review Specialist (RN), Care Management staff, physicians, Vice President of Medical Affairs, CDI, Revenue Cycle, Patient Access, and the Business Office. This role serves as the clinical support bridge between the non-clinical UR administrative function and the licensed RN UR Specialist, operating under the supervision of licensed nursing staff for all clinically related tasks.

The Utilization Review Clinical Associate (URCA) provides clinically informed support to the inpatient Utilization Review (UR) team at Carteret Health Care. This role is distinguished from the non-clinical Utilization Review Support Specialist (URSPEC) by requiring an active clinical license or credential and by performing functions that require clinical knowledge and judgment at a support level, under the supervision and direction of the RN UR Specialist. The URCA assists with concurrent review activities, functional and discharge readiness assessment support, clinical documentation coordination, level-of-care data collection, and payer communication support. The URCA does not independently perform medical necessity determinations or make inpatient/observation status decisions; those functions remain with the RN UR Specialist and Physician Advisor. The URCA enhances team capacity by bridging clinical and administrative UR functions, reducing burden on licensed UR nursing staff, and contributing clinical perspective to care transitions and discharge planning coordination.

Qualifications:

• Professional active clinical license or credential required. Qualifying credentials include: Licensed Practical Nurse (LPN), Physical Therapist (PT), Occupational Therapist (OT), Physical Therapist Assistant (PTA), Certified Occupational Therapy Assistant (COTA), Speech-Language Pathologist (SLP), Respiratory Therapist (RT), Medical Assistant (CMA/RMA), or equivalent clinically credentialed healthcare professional. Credential must be in good standing with the applicable state licensing board.
• Preferred (2) years of clinical experience in an acute care hospital, rehabilitation, skilled nursing, or related inpatient/post-acute setting preferred.
• Working knowledge of medical terminology, clinical documentation, and patient care workflows in an inpatient environment.
• Familiarity with insurance terminology, prior authorization processes, and payer-specific concurrent review requirements preferred.
• Familiarity with CMS rules relevant to inpatient care (e.g., Two-Midnight Rule, inpatient vs. observation status, Important Message from Medicare, MOON notice) preferred; training will be provided.
• Proficiency with Microsoft Office (Outlook, Word, Excel) and ability to learn hospital information systems (Meditech, Midas, Providerlink, payer portals).
• A certification such as Certified Case Manager (CCM), Certified Utilization Review Professional (CURP), or Certified Revenue Cycle Specialist (CRCS) is a plus but not required.