Clinical Quality & Utilization Review Specialist

Job Summary

Under the supervision of the Director of Utilization Management, the Clinical Quality and Utilization Review Specialist performs a dual role encompassing utilization management and peer review. This position is responsible for assessing the medical appropriateness, efficiency, and quality of healthcare services across inpatient and outpatient settings, including authorization review and utilization oversight. In parallel, the RN coordinates peer review activities including screening, reviewing, and preparing cases and facilitating Root Cause Analyses (RCAs) to evaluate clinical performance and identify opportunities for improvement.

Essential Functions

• Coordinate and facilitate peer review activities in alignment with medical staff bylaws, organizational policies, and accreditation standards.

• Screen, review, and prepare cases for peer review committees, ensuring completeness, objectivity, and readiness for evaluation.

• Partner with physician and APP reviewers to support fair, consistent, and evidence-based evaluation of clinical care.

• Track, document, and communicate peer review outcomes, ensuring timely feedback, follow-up, and provider education.

• Maintain strict confidentiality of peer review activities and records in accordance with legal and regulatory requirements.

• Support preparation and coordination of clinical quality and peer review committee meetings and associated materials.

Quality Improvement & Patient Safety

• Participate in Root Cause Analyses (RCAs) for sentinel events, near misses, and high-risk occurrences.

• Collaborate with interdisciplinary teams to identify contributing factors, system vulnerabilities, and opportunities for improvement.

• Support development, implementation, and monitoring of corrective action plans.

• Lead or support quality improvement initiatives informed by utilization data, peer review findings, and organizational priorities.

• Apply evidence-based methodologies (e.g., PDSA, Lean, Six Sigma) to drive measurable improvements in care quality and efficiency.

• Prepare and deliver reports, dashboards, and presentations on utilization, peer review, and quality outcomes.

• Provide education and coaching to staff and providers on quality improvement principles and findings.

Utilization Management

• Perform comprehensive utilization reviews and manage authorizations for inpatient and outpatient services, including skilled nursing, home health, durable medical equipment (DME), and other clinical programs.

• Assess medical necessity, appropriateness of care, and level of service using established clinical criteria and guidelines.

• Review providers’ contracts and approve healthcare services as specified in these contracts.

• Collaborate with physicians, case managers, social workers, and care teams to ensure coordinated, patient-centered care and optimal outcomes.

• Conduct telephonic and email-based outreach to the provider community, as appropriate, as part of the utilization review work.

• Obtain, review, and analyze clinical documentation to support authorization decisions and ensure regulatory compliance.

• Communicate determinations and recommendations clearly and professionally with internal and external stakeholders.

• Ensure accurate and timely documentation in the electronic health record, or utilization review database, maintaining compliance with organizational and regulatory standards.

• Participate in the appeals process as needed, providing clinical expertise and supporting documentation.

• Monitor utilization trends and identify opportunities to improve efficiency and care delivery.

• Participate in the utilization review/utilization management committee and effectively contribute to the functioning of the committee work.

Collaboration & Organizational Support

• Partner with the Medical Executive Board (MEB) designee and medical staff leadership to support peer review, quality, and patient safety activities in alignment with medical staff bylaws and organizational priorities.

• Exercise independent judgment in coordinating peer review processes, ensuring consistency, fairness, and adherence to established clinical standards.

• Support and coordinate committees and workgroups related to utilization management, peer review, and clinical quality, including preparation of materials and follow-up on action items.

• Serve as a liaison between administrative leadership, medical staff, and interdisciplinary teams to advance utilization and quality initiatives.

• Promote a culture of safety, accountability, professionalism, and continuous improvement.

• Demonstrate commitment to organizational mission, values, and health equity goals.