Clinical Utilization Review Specialist

Bradford Health Services; Knoxville (TN); On-site; USD 65,000 - 90,000; Full time

Benefits offered by this job

Medical coverage

Employee Assistance Program (EAP) with

Retirement plan 401(k) with Voya

Generous PTO

Job summary

Bradford Health Services seeks a diligent Utilization Review Specialist to ensure medical necessity, efficiency, and regulatory compliance across patient care. You will evaluate records, treatment plans, and clinical data while collaborating with providers, insurers, and case managers to obtain information and secure timely approvals.

This role emphasizes strong analytical, communication, and organizational skills, with knowledge of payer policies and healthcare regulations guiding decisions on

Qualifications

• Bachelor’s degree in healthcare or related field.
• At least 2 years of 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 medical records and clinical data to assess necessity and appropriateness of services.
• Coordinate with providers, insurers, and case managers to obtain information and clarify details.
• Make authorization decisions based on clinical guidelines and regulatory requirements.
• Maintain accurate records of utilization review activities and decisions.
• Stay current with evolving healthcare regulations and payer policies.

Skills

Analytical skills

Communication skills

Organizational skills

Healthcare terminology knowledge

Regulatory knowledge

Insurance authorization processes

Education

Bachelor's degree in healthcare or related field

Tools

EHR software

Utilization management software

Job description

Bradford Health Services seeks a diligent Utilization Review Specialist to ensure medical necessity, efficiency, and regulatory compliance across patient care. You will evaluate records, treatment plans, and clinical data while collaborating with providers, insurers, and case managers to obtain information and secure timely approvals.

This role emphasizes strong analytical, communication, and organizational skills, with knowledge of payer policies and healthcare regulations guiding decisions on