Clinical Utilization Specialist

1 week ago


Middleborough Center, Massachusetts, United States McLean Hospital(MCL) Full time
Job Summary

McLean Hospital(MCL) seeks a skilled Clinical Utilization Specialist to perform concurrent reviews of outpatient and in-patient claims and authorization reviews of patient services. The ideal candidate will pursue high-quality medical outcomes for patients requiring precertification/preauthorization.

Key Responsibilities

Assess, review, and assign cases for utilization review (UR)
Assist with negotiations of access to care in targeted areas; maintain relationships with providers
Prepare clinical information for each concurrent review directly from the medical record
Protect healthcare organization value by keeping information confidential
Facilitate effective communication between treatment team members
Maintain compliance with regulation changes affecting utilization management
Use screening criteria, knowledge, and clinical judgment to assess patient needs
Recognize and report cases of fraud, abuse, or mis-utilization

Qualifications

Bachelor's degree in Social Work, Nursing, or Licensed Mental Health Counselor
Social Worker, Licensed Clinical (LCSW - State License) or Registered Nurse (RN - State License) preferred
Clinical experience, including during training, working with Rehab, psychiatric in-patient population

What We Offer

McLean Hospital(MCL) offers a dynamic work environment, competitive salary, and comprehensive benefits package.

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