Clinical Utilization Specialist

3 weeks ago


Boston, Massachusetts, United States McLean Hospital Full time
Job Summary

As a Utilization Reviewer at McLean Hospital, you will play a critical role in ensuring high-quality medical outcomes for patients who require precertification/preauthorization. This position involves performing concurrent reviews of outpatient and in-patient claims, as well as authorization reviews of patient services.

Key Responsibilities
  • Assess, review, and assign cases for utilization review (UR)
  • Assist with negotiations of access to care in specified targeted areas; maintain relationships with providers who provide services to patients and pursue a responsive system for authorization of services and approved claims
  • Prepare clinical information for each concurrent review directly from the medical record
  • Protect healthcare organization value by keeping information confidential; cautioning others regarding potential breaches
  • Facilitate effective communication between members of the treatment team
  • Maintain compliance with regulation changes affecting utilization management
  • Use appropriate screening criteria, knowledge, and clinical judgment to assess patient needs
  • Recognize and report appropriately cases of fraud, abuse, or mis-utilization
  • Ensure quality and quantity of documentation in medical records for UR
Qualifications
  • Education: Social work, Nursing, Licensed mental health counselor
  • Licenses and Certifications: Social Worker, Licensed Clinical LCSW - State License preferred; Registered Nurse RN - State License preferred; Licensed Mental Health Counselor State License preferred
  • Work Experience: Clinical experience, including during training, working with Rehab, psychiatric in-patient population


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