Clinical Utilization Specialist

4 weeks ago


New Haven, Connecticut, United States Yale University Full time
Job Summary

Yale University seeks a skilled Clinical Utilization Specialist to join its team. The successful candidate will be responsible for optimizing healthcare resource utilization through thorough reviews of patient cases, ensuring compliance with established guidelines and medical necessity criteria.

Key Responsibilities:

  • Conduct thorough reviews of patient cases to assess the necessity and appropriateness of medical services and treatments.
  • Evaluate clinical documentation to ensure compliance with established guidelines, medical necessity criteria, and payer requirements.
  • Review and process authorization requests for medical procedures, diagnostic tests, and hospital admissions.
  • Collaborate with healthcare providers and care management teams to gather additional information, clarify treatment plans, and address any discrepancies.

Requirements:

  • Bachelor's Degree in Nursing and two years' experience or an equivalent combination of education and experience.
  • Strong clinical assessment and critical thinking skills.
  • Excellent communication and interpersonal skills.
  • Capable of detailed understanding of the healthcare benefits package, identifying cases and situations in which clarification and timely decision making are needed.

Preferred Qualifications:

  • Master's Degree in Nursing or Healthcare Administration.
  • Certification in Utilization Review (CPUR or equivalent).

About Yale University:

Yale University is a tobacco-free campus and an equal opportunity employer.



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