Utilization Review Specialist

The UR Specialist reviews and monitors patients’ utilization of health care services with the goal of maintaining high quality, cost-effective care. The duties include providing the medical and utilization expertise necessary to evaluate the appropriateness and efficiency of medical services and procedures.

• Performs concurrent and retrospective reviews on all patients. Monitors level and quality of care.
• Responsible for the proactive management of patients with the objective of improving quality outcomes and decreasing costs.
• Evaluates and provides feedback to treating physicians regarding a patient’s discharge plans and available covered services, including identifying alternative levels of care that may be covered.
• Monitors all utilization reports to assure compliance with reporting and turnaround times.
• Addresses care issues with the Director of Clinical Services and Chief Medical Officer/Medical Director as appropriate.
• Coordinates an interdisciplinary approach to support continuity of care.
• Provides utilization management, transfer coordination, discharge planning, and issuance of all appropriate authorization for covered services as needed.
• Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum.
• Clarifies health plan medical benefits, policies and procedures for members, physicians, staff, contract providers, and outside agencies.

Requirements

Requirements

• Bachelor's degree in Social Work or related field required.
• Clinical Licensure in the State of Nevada preferred, no required
• Knowledge of medical terminology, medical records, and appropriate medical coding system.
• Working knowledge with software and/or equipment (Microsoft Office applications including Outlook, Word, Excel and PowerPoint).
• Maintains confidentiality of patients at all times.

Benefits

We proudly offer the following benefits available first of the month following just one month of employment:

• Competitive rates
• Flexible schedules
• Tuition reimbursement
• Comprehensive package of benefits to include:
  • Medical
  • Dental
  • Vision

• Life, Pet, Identity Theft Insurance
• 401k
• Generous paid time off
• Short Term and Long Term Disability