Utilization Review Specialist

To support effective utilization management, the part-time Senior Utilization Review Specialist will conduct concurrent and retrospective reviews of hospital services, ensuring compliance with medical necessity and payer authorization while collaborating with clinical teams in a fully remote capacity. Key Responsibilities Perform concurrent and retrospective utilization reviews for inpatient, observation, and outpatient cases using approved criteria and clinical judgment Collaborate with physicians and care management teams to clarify documentation and support appropriate care progression while identifying and escalating potential risks Serve as a senior clinical resource, providing guidance on complex review questions and participating in quality audits and process improvement initiatives Required Qualifications Current, unrestricted RN license Five or more years of acute-care hospital experience, including at least three years in utilization review or a closely related function Demonstrated experience applying medical-necessity and level-of-care criteria Working knowledge of payer authorization requirements and denial-prevention practices Strong clinical judgment and ability to manage a high-volume caseload independently