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Clinical Utilization Review Specialist

2 months ago

Irving, Texas, United States Impresiv Health Full time
About the Role

We are seeking a highly skilled and experienced Clinical Utilization Review Specialist to join our team at Impresiv Health. As a key member of our clinical operations team, you will play a critical role in ensuring the efficient and effective delivery of healthcare services to our clients.

Key Responsibilities
  • Medical Necessity Reviews: Conduct comprehensive medical necessity reviews to determine the appropriateness of care provided to patients and ensure proper hospital resource utilization.
  • Clinical Appropriateness: Utilize approved screening criteria to assess the clinical appropriateness of care and ensure that patients receive the most effective and efficient treatment options.
  • Communication and Collaboration: Effectively communicate with internal and external clinical professionals to ensure seamless coordination of patient care and resolve any issues related to clinical appropriateness recommendations, coverage, and potential or actual payor denials.
  • Regulatory Compliance: Maintain current and accurate knowledge of regulatory requirements related to utilization review and ensure compliance with all relevant laws and regulations.
  • Case Management: Proactively identify and resolve issues related to clinical appropriateness recommendations, coverage, and potential or actual payor denials, and coordinate certification of hospital services with payors as needed.
  • Quality Improvement: Evaluate care administered by the interdisciplinary healthcare team and advocate for standards of practice to ensure high-quality patient care.
Requirements
  • Education: Associate of Nursing Degree required, BSN preferred.
  • Experience: 2+ years of experience in Utilization Review.
  • Certifications: RN License for state of employment required, compact accepted. Certification in Case Management preferred.
  • Skills: Excellent written and verbal communication skills, critical and analytical thinking skills, and knowledge of criteria sets including InterQual and MCG.
About Impresiv Health

Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.