Utilization Reviewer

Job Description

Job Summary:

The Utilization Reviewer is responsible for reviewing medical services and treatment plans to ensure they are medically necessary, appropriate, and in compliance with payer guidelines and regulatory requirements. This role helps optimize the use of healthcare resources by evaluating clinical documentation against established criteria.Key Responsibilities:

Review clinical documentation to determine medical necessity for proposed treatments, procedures, or hospital admissions.

Apply evidence-based guidelines (e.g., MCG, InterQual) and payer-specific criteria in review processes.

Coordinate with physicians, nurses, and other healthcare professionals to obtain necessary information for case review.

Make timely decisions on authorization requests and communicate determinations clearly and professionally.

Prepare and document clinical reviews and decisions accurately in the utilization review system.

Participate in appeals processes by preparing detailed case summaries and collaborating with medical directors.

Monitor patient progress and ongoing need for care through concurrent and retrospective review.

Maintain up-to-date knowledge of clinical guidelines, regulatory changes, and insurance policies.

Ensure compliance with federal, state, and accreditation standards (e.g., CMS, NCQA, URAC).

Provide utilization data and trends to help improve patient care and resource management.Qualifications:

Education & Licensure:

RN, LPN, or other licensed clinical professional (depending on organization)

Active, unencumbered license in the state of practice

Utilization Review certification (e.g., CPHQ, CM, CCM) preferred

Experience:

2–5 years of clinical experience in a healthcare setting

1–3 years of experience in utilization management, case management, or quality assurance preferred

Skills:

Strong understanding of medical terminology, treatment protocols, and insurance requirements

Proficient in using utilization review software and electronic health records (EHRs)

Excellent analytical, communication, and decision-making skills

Ability to work independently and meet strict deadlines

Full-time