Utilization Review Specialist

About the role

The Utilization Review (UR) Specialist evaluates patient medical records to ensure treatments meet clinical necessity and regulatory standards. You will serve as the primary bridge between our medical staff and insurance providers, facilitating timely care approvals and minimizing claim denials.

Responsibilities

• Evaluate outpatient charts against established clinical criteria
• Submit and track insurance authorization requests
• Draft and submit clinical appeals for denied services
• Communicate directly with insurance medical directors and case managers
• Advise physicians and clinical staff on documentation requirements
• Monitor utilization trends, denial rates, and approval timelines
• Ensure adherence to Medicare, Medicaid, and private payer guidelines
• Retrieve discharge documents daily from charts and fax when applicable
• Retrieve authorizations

Requirements

• Current LPN, RN, or other Clinical Licensure and/or master's degree required
• Minimum two (2) years of clinical experience, with 1+ years in utilization review or case management required
• Knowledge of Nevada Payors required
• Previous experience working in behavioral healthcare strongly preferred
• Strong Microsoft Word and Excel skills required
• Maintains confidentiality of patients at all times

Schedule

Monday - Friday from 8:00am - 4:30pm

Benefits

Eligible for benefits 1st of the month following one month of employment.

• Health insurance
• Vision insurance
• Dental insurance
• 401K Retirement Plan
• Healthcare spending account
• Dependent care spending account
• PTO Plan with holiday premium pay
• Discounted cafeteria meal plan
• Life insurance (Supplemental Life, Term, and Universal plans are also available)
• Short- and long-term disability (with additional buy-in opportunities)