Clinical Utilization Specialist
2 weeks ago
Position Overview: The Clinical Utilization Specialist plays a pivotal role in the Utilization Management process, acting as a key resource under general supervision. This position involves collaboration with healthcare professionals to ensure adherence to regulatory standards and promote optimal patient care.
Key Responsibilities:
- Documentation Analysis: Assess and interpret intricate medical records to ensure compliance with medical necessity criteria.
- Clinical Collaboration: Work closely with a multidisciplinary team, including attending physicians, residents, and mid-level practitioners.
- Critical Evaluation: Utilize analytical skills to determine cases that require further review by external consultants and internal medical directors.
- Insurance Coordination: Provide precise and timely clinical information to insurance providers to facilitate decision-making.
- Appeals Management: Evaluate denied cases and determine the appropriateness of appeals based on medical guidelines and contractual obligations.
- External Engagement: Conduct appeals with external organizations and oversee the resolution of disputed cases.
- Financial Stewardship: Support the financial objectives of the department through effective management of utilization processes.
- Professional Development: Engage in continuous professional growth and contribute to the development of peers.
- Leadership Role: Exhibit leadership qualities within the Utilization Management framework.
- Additional Duties: Perform other responsibilities as assigned to support departmental goals.
Compensation: Competitive salary range based on experience and qualifications.
Minimum Qualifications:
- Education: Bachelor of Science in Nursing from an accredited institution.
- Experience: Minimum of 2 years in an acute care hospital setting.
- Licensure: Valid Registered Nurse license in the Commonwealth of Virginia.
Preferred Qualifications:
- Experience: At least 3 years in diverse nursing roles within acute, medical-surgical, or adult care environments.
Physical Requirements: The role requires prolonged periods of sitting, effective communication skills, attention to detail, and legible writing.
The organization is committed to fostering a diverse workforce and encourages applications from individuals of all backgrounds and experiences.
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