UR (Utilization Review) Specialist

Job Summary

The Utilization Review (UR) Specialist is responsible for assessing healthcare services provided to patients to ensure they are medically necessary, appropriate, and aligned with insurance guidelines. This role involves reviewing patient records, collaborating with healthcare providers, and making recommendations for continued care, discharge, or alternative treatments. Ideal candidates have strong analytical skills, a clinical background, and a commitment to ensuring optimal resource use and patient care.

Responsibilities

• Review patient medical records to assess the necessity, appropriateness, and efficiency of healthcare services.
• Collaborate with healthcare providers and insurance representatives to determine and authorize appropriate levels of care.
• Conduct initial, concurrent, and retrospective reviews for admissions, treatments, and procedures.
• Provide recommendations regarding continued care, transfers, and discharge planning based on evidence-based guidelines and insurance policies.
• Document and track utilization review activities accurately in compliance with organizational and regulatory standards.
• Communicate effectively with physicians, nurses, and insurance providers to coordinate patient care and resolve authorization issues.
• Stay updated on industry standards, regulatory requirements, and best practices in utilization management.

Skills and Qualifications

• Strong analytical skills with the ability to assess clinical information accurately.
• Knowledge of medical terminology, healthcare practices, and insurance guidelines.
• Excellent communication and interpersonal skills for interacting with healthcare providers and insurance representatives.
• Organizational skills and attention to detail to manage multiple cases and documentation accurately.
• Ability to work independently and make objective decisions based on clinical guidelines.

Preferred Skills

• Clinical background as an RN, LPN, or other licensed healthcare provider.
• Experience in utilization review, case management, or healthcare administration.
• Familiarity with utilization management software and electronic health records (EHR).