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Clinical Utilization Review Specialist
2 months ago
At UCLA Health, we're seeking a highly skilled Clinical Utilization Review Specialist to join our team. As a key member of our healthcare organization, you'll play a vital role in promoting high-quality, cost-effective medical care.
Key Responsibilities:
- Apply clinical acumen and applicable policies and guidelines in the issuance of adverse organization determinations.
- Review medical records for appropriate care and setting, working closely with denial coordinators and other staff to ensure accurate processing of written notifications.
- Provide clinical guidance on denial cases and ensure that all denial letters are written and issued according to internal policies and NCQA, health plan, federal, and state requirements.
Requirements:
- Current CA LVN licensure required.
- Two or more years of utilization review/utilization management experience in an HMO, MSO, IPA, or health plan environment.
- Previous clinical experience.
- Experience drafting and issuing compliant adverse organization determinations.
- In-depth knowledge of health plan, DMHC, CMS, HIPPA, and NCQA requirements.
- Expertise in abstracting and interpreting medical information from patient records.
- Strong communication, interpersonal, analytical, problem-solving, organizational, and prioritizing skills.
- Thorough understanding of the Hierarchy of Clinical Criteria.
- Experience with Flesch-Kincaid readability scoring.
- Knowledge of the appeals process.
- Experience with audit preparation.
- Basic computer skills.
About UCLA Health:
We're a world-renowned health system with four award-winning hospitals and more than 250 community clinics throughout Southern California. Our mission is to provide exceptional, compassionate patient care, and we're committed to fostering a diverse and inclusive work environment.
