About the Role
The role involves reviewing and validating the medical necessity of inpatient and outpatient services, ensuring compliance with payer and regulatory requirements, and supporting effective resource use across care settings.
Responsibilities
- Assess patient cases to determine medical necessity and appropriateness of care levels
- Conduct prospective, concurrent, and retrospective utilization reviews
- Collaborate with healthcare providers to gather clinical documentation
- Verify adherence to evidence-based guidelines and payer policies
- Communicate findings and recommendations to case management and clinical teams
- Facilitate timely authorizations and referrals with insurance carriers
- Document review outcomes in the electronic health record system
- Monitor length of stay and identify potential barriers to discharge
- Support quality improvement initiatives related to care management
- Participate in interdisciplinary team meetings and care coordination discussions
- Respond to payer inquiries and appeals regarding utilization decisions
- Maintain up-to-date knowledge of CMS, NCQA, and other regulatory standards
- Ensure compliance with internal policies and external accreditation requirements
- Assist in training staff on utilization review processes and documentation standards
- Track and report key performance metrics for utilization management
Compensation
Competitive salary based on experience and qualifications
Work Arrangement
Full-time, day shift
Team
Integrated within the care management department, collaborating with nurses, physicians, and administrative staff
Why Join Us
- Opportunity to contribute to high-quality, patient-centered care
- Supportive work culture focused on professional growth
- Comprehensive benefits package including health, dental, and retirement options
- Access to wellness programs and employee development resources
Equal Opportunity Employer
- We are committed to diversity and inclusion in the workplace
- All qualified applicants will receive consideration without regard to race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability
Not available
