Advanced Utilization Review Specialist

Chesapeake Regional Healthcare; Chesapeake (VA); On-site; USD 60,000 - 85,000; Full time

Job summary

Chesapeake Regional Healthcare seeks a dedicated Utilization Review Specialist to support the organization’s utilization management program in Virginia. You will conduct admission, concurrent, and retrospective reviews following established criteria and document clinical information to support medical necessity determinations.

Complex cases are referred to an RN Utilization Review for evaluation; you will assist with payer authorizations, maintain records, and participate in quality-improvement

Qualifications

• Graduate of an approved healthcare program leading to licensure as a healthcare professional (LPN or other clinically licensed professional).
• Two years of clinical healthcare experience required. Experience in utilization review or care coordination is a plus.

Responsibilities

• Conduct routine utilization reviews using approved criteria and workflows.
• Collect and organize clinical documentation to support utilization review activities.
• Review patient records for admission, continued stay, and discharge planning.
• Apply established criteria and document findings in designated systems.
• Monitor cases for required documentation and timely review completion.
• Communicate with providers, payers, and care team members to obtain information.
• Escalate cases not clearly meeting criteria to an RN Utilization Review.
• Assist with payer authorizations and tracking status.
• Maintain utilization management records and audit documentation.
• Support denial prevention through timely documentation.
• Participate in quality improvement initiatives.

Skills

Clinical documentation

Communication

Data collection

Education

Licensed Practical Nurse (LPN)

Tools

EHR systems

Job description

Chesapeake Regional Healthcare seeks a dedicated Utilization Review Specialist to support the organization’s utilization management program in Virginia. You will conduct admission, concurrent, and retrospective reviews following established criteria and document clinical information to support medical necessity determinations.

Complex cases are referred to an RN Utilization Review for evaluation; you will assist with payer authorizations, maintain records, and participate in quality-improvement