UTILIZATION REVIEW SPECIALIST
Review Medical Records: Analyze patient records and clinical documentation to assess the necessity and appropriateness of care.
Authorization Decisions: Approve or recommend denial of coverage for procedures, tests, hospital stays, and treatments.
Communicate With Providers: Discuss cases with doctors, nurses, or case managers to clarify or justify treatment decisions.
Appeals & Denials: Handle or assist with appeals for denied services or claims.
Data Entry & Reporting: Document decisions in systems, and produce reports for management or compliance.
Stay Updated: Keep current with changing policies, guidelines, and healthcare regulations.
SKILLS:
Clinical knowledge (for medical record review)
Critical thinking and judgment
Attention to detail
Familiarity with healthcare regulations (e.g., Medicare, Medicaid, HIPAA)
Communication and negotiation
Ability to work with UR software
