Clinical Utilization Review Specialist

Community Health Systems; United States; On-site; USD 70,000 - 90,000; Full time

Job summary

Community Health Systems is hiring a Clinical Utilization Review Specialist responsible for evaluating hospital service necessity, ensuring compliance with management policies, and collaborating with healthcare teams. This full-time role requires strong skills in utilization management, documentation, and patient care facilitation.

Candidates should possess an Associate Degree in Nursing and have several years of clinical experience. Join a team focused on enhancing patient care and optimizing hospital resource use.

Qualifications

• 2-4 years of clinical experience in utilization review or acute care nursing.
• 1-2 years of experience in utilization management preferred.
• Registered Nurse state licensure required.

Responsibilities

• Evaluate hospital services for compliance with utilization management policies.
• Conduct admission and continued stay reviews.
• Document utilization review activities in case management software.

Skills

Utilization management principles

Communication skills

Analytical skills

Attention to detail

Education

Associate Degree in Nursing

Bachelor's Degree in Nursing

Tools

Case management software

Electronic Health Records (EHR)

Job description

Job Summary

The Clinical Utilization Review Specialist is responsible for evaluating the necessity, appropriateness, and efficiency of hospital services to ensure compliance with utilization management policies. This role conducts admission and continued stay reviews, supports denials and appeals activities, and collaborates with healthcare providers to facilitate efficient patient care. The Clinical Utilization Review Specialist monitors adherence to hospital utilization review plans and works to optimize hospital resource utilization, reduce readmissions, and maintain compliance with payer requirements.

Essential Functions

• Performs admission and continued stay reviews using evidence-based criteria, clinical expertise, and regulatory guidelines to ensure appropriate utilization of hospital services.
• Collaborates with physicians and clinical teams to obtain necessary documentation for medical necessity, discharge planning, and payer requirements.
• Documents all utilization review activities in the hospital’s case management software, including clinical reviews, escalations, avoidable days, payer communications, and authorization details.
• Works with insurance companies to secure coverage approvals and mitigate concurrent denials by submitting reconsiderations or coordinating peer-to-peer reviews.
• Communicates effectively with utilization review coordinators, case managers, and discharge planners to ensure a collaborative approach to patient care.
• Analyzes trends in hospital admissions and extended stays, identifying opportunities for process improvements to enhance utilization management.
• Serves as a key contact for facility staff and insurance representatives regarding utilization review concerns.
• Supports training initiatives within the department and escalates complex issues to management as needed.
• Performs other duties as assigned.
• Maintains regular and reliable attendance.
• Complies with all policies and standards.

Qualifications

• Associate Degree in Nursing required
• Bachelor's Degree in Nursing preferred
• 2-4 years of clinical experience in utilization review, case management, or acute care nursing required
• 1-3 years work experience in care management preferred
• 1-2 years of experience in utilization management, payer relations, or hospital revenue cycle preferred

Knowledge, Skills and Abilities

• Strong knowledge of utilization management principles, payer guidelines, and regulatory requirements.
• Proficiency in case management software and electronic health records (EHR).
• Excellent communication and collaboration skills to work effectively with interdisciplinary teams and external payers.
• Strong analytical and problem-solving skills to assess utilization trends and optimize hospital resource use.
• Ability to work in a fast-paced environment while maintaining attention to detail and accuracy.
• Knowledge of HIPAA regulations and patient confidentiality standards.

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure required
• CCM - Certified Case Manager preferred
• Accredited Case Manager (ACM) preferred

Job Info

• Job Identification 154227
• Job Category Administrative Support
• Posting Date 06/08/2026, 02:08 PM
• Job Schedule Full time
• Job Shift Day
• Locations 4000 Meridian Blvd, Franklin, TN, 37067, US