Care Utilization & Approvals Specialist

Bradford Health Services; Southaven (MS); On-site; USD 55,000 - 75,000; Full time

Benefits offered by this job

Medical coverage

Employee Assistance Program (EAP)

Student loan repayment

Job summary

Bradford Health Services seeks a skilled Utilization Review Specialist to ensure medical necessity and regulatory compliance in patient care. You will evaluate records and treatment plans, and collaborate with providers, insurers, and case managers to obtain timely approvals and optimize outcomes.

Minimum qualifications include a Bachelor’s degree in healthcare, 2+ years in utilization review or related roles, strong medical terminology knowledge, and familiarity with insurance authorization and

Qualifications

• Bachelor’s degree in a healthcare or related field.
• At least 2 years of experience in utilization review, case management, or clinical healthcare roles.
• Strong knowledge of medical terminology, clinical procedures, and healthcare regulations.
• Familiarity with insurance authorization processes and healthcare reimbursement models.
• Excellent analytical, communication, and organizational skills.

Responsibilities

• Review and analyze medical records, treatment plans, and clinical documentation to assess necessity and appropriateness of services.
• Coordinate with healthcare providers, insurance representatives, and case managers to obtain additional information and clarify treatment details.
• Make informed decisions regarding authorization, continuation, modification, or denial of services based on clinical guidelines and regulatory requirements.
• Maintain accurate and detailed records of utilization review activities, decisions, and communications in compliance with policies and legal standards.
• Stay current with evolving healthcare regulations, payer policies, and clinical best practices to ensure compliant review processes.

Skills

Analytical skills

Communication skills

Organizational skills

Regulatory knowledge

Education

Bachelor's degree in healthcare

Job description

Bradford Health Services seeks a skilled Utilization Review Specialist to ensure medical necessity and regulatory compliance in patient care. You will evaluate records and treatment plans, and collaborate with providers, insurers, and case managers to obtain timely approvals and optimize outcomes.

Minimum qualifications include a Bachelor’s degree in healthcare, 2+ years in utilization review or related roles, strong medical terminology knowledge, and familiarity with insurance authorization and