Utilization Review Specialist (Flexi)

Essential Duties And Responsibilities

• Conduct routine utilization reviews using approved screening criteria, established workflows, and departmental guidelines.
• Collect and organize clinical documentation necessary to support utilization review activities.
• Review patient records to identify required information for admission, continued stay, and discharge planning processes.
• Apply established criteria to routine cases and document findings in designated systems.
• Monitor assigned cases for required documentation and timely review completion.
• Communicate with providers, clinical staff, payers, and care team members to obtain necessary information.
• Identify cases that do not clearly meet established criteria and escalate them to an RN Utilization Review.
• Present complex, high-acuity, disputed, or clinically ambiguous cases to an RN Utilization Review Specialist for evaluation and determination.
• Absorb and communicate payer authorizations and track authorization status as directed.
• Maintain accurate utilization management records, reports, and audit documentation.
• Support denial prevention efforts through timely documentation and communication.
• Participate in quality improvement initiatives related to utilization management processes.
• Maintain knowledge of applicable payer requirements, regulatory standards, and organizational policies.
• Absorb and assist with data collection and reporting related to utilization management metrics.
• Perform other utilization management support duties within the scope of licensure and training.

Qualifications

• Minimum Required Education: Graduate of an approved healthcare program leading to licensure as a healthcare professional i.e. Licensed Practical Nurse (LPN) or other clinically licensed healthcare professionals as approved by the organization.
• Experience: Two (2) years of clinical healthcare experience required. Experience in utilization review, utilization management, case management, care coordination, discharge planning, or other related clinical healthcare functions may be considered.
• Certification: Current unrestricted license as a Licensed Practical Nurse required at minimum in the Commonwealth of Virginia or compact state. Candidates possessing a higher level of clinical licensure are also eligible for consideration. Certification in utilization management or case management preferred.