Healthcare Utilization Review Expert

Automatic Data Processing, Inc.; Lucedale (MS); On-site; USD 55,000 - 90,000; Full time

Benefits offered by this job

Medical coverage

Retirement benefits

Generous PTO

Voluntary Benefits for Part-Time

Student Loan Repayment

Job summary

Bradford Health Services is seeking an Utilization Review Specialist to evaluate medical records and treatment plans for medical necessity and efficiency. You will collaborate with doctors, insurers, and case managers to secure timely approvals and optimize patient outcomes.

The role requires a healthcare-related Bachelor's degree and 2+ years in utilization review or case management, with strong knowledge of medical terminology and payer guidelines.

Qualifications

• Bachelor's degree in a healthcare or related field is required.
• 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 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, 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 organizational policies and legal standards.
• Stay current with evolving healthcare regulations, payer policies, and clinical best practices to ensure consistent and compliant review processes.

Skills

Analytical skills

Communication skills

Organizational skills

Healthcare terminology knowledge

Education

Bachelor's degree in healthcare or related field

Tools

EHR systems

Utilization management software

Job description

Bradford Health Services is seeking an Utilization Review Specialist to evaluate medical records and treatment plans for medical necessity and efficiency. You will collaborate with doctors, insurers, and case managers to secure timely approvals and optimize patient outcomes.

The role requires a healthcare-related Bachelor's degree and 2+ years in utilization review or case management, with strong knowledge of medical terminology and payer guidelines.