Clinical Utilization Review Specialist

Addiction-and-Mental-Health-Services,-LLC; Lucedale (MS); On-site; USD 55,000 - 75,000; Full time

Benefits offered by this job

Medical coverage

Retirement benefits 401(k)

Generous PTO

Voluntary benefits

Job summary

Bradford Health Services in Lucedale, Mississippi, is seeking a dedicated Utilization Review Specialist to ensure medical necessity, efficiency, and regulatory compliance in patient care. The role collaborates with providers, insurers, and case managers to streamline approvals and optimize outcomes.

The ideal candidate will hold a healthcare degree with at least 2 years in utilization review or related fields, possess strong regulatory knowledge, and excel in analytical communication.

Qualifications

• Bachelor’s degree in Nursing, Health Administration, or a related healthcare field.
• At least 2 years of experience in utilization review, case management, or clinical healthcare roles.
• Familiarity with insurance authorization processes and utilization management guidelines.

Responsibilities

• Review and analyze medical records, treatment plans, and clinical documentation to assess the necessity and appropriateness of healthcare services.
• Coordinate with healthcare providers, insurance representatives, and case managers to obtain additional information and clarify treatment details.
• Make informed decisions regarding authorization, continuation, or denial of services based on clinical guidelines, policies, and regulatory requirements.
• Document findings and decisions accurately in electronic health record systems and prepare detailed reports for internal and external stakeholders.
• Stay current with healthcare regulations, insurance policies, and clinical best practices to ensure compliance and effective utilization management.

Skills

Utilization review

Case management

Healthcare regulations

Communication skills

Insurance authorization processes

Education

Bachelor’s degree in Nursing or Health Administration

Tools

Electronic health records (EHR)

Utilization review software

Job description

Bradford Health Services in Lucedale, Mississippi, is seeking a dedicated Utilization Review Specialist to ensure medical necessity, efficiency, and regulatory compliance in patient care. The role collaborates with providers, insurers, and case managers to streamline approvals and optimize outcomes.

The ideal candidate will hold a healthcare degree with at least 2 years in utilization review or related fields, possess strong regulatory knowledge, and excel in analytical communication.