Strategic Utilization Review Clinician

Community Health Systems; United States; On-site; USD 70,000 - 100,000; Full time

Job summary

Community Health Systems is seeking a Clinical Utilization Review Specialist in the United States. The role evaluates the necessity and efficiency of healthcare services, conducting admissions reviews and supporting denials and appeals activities.

The position collaborates with physicians and interdisciplinary teams to secure documentation for medical necessity and discharge planning, ensuring alignment with payer requirements and utilization plans.

Qualifications

• Strong knowledge of utilization management principles, medical necessity criteria, payer guidelines.
• Familiarity with HIPAA and patient confidentiality requirements.
• Proficiency with case management software and EHR systems.
• Excellent communication and collaboration with interdisciplinary teams.

Responsibilities

• Performs admission and continued stay reviews using evidence-based criteria.
• Collaborates with physicians and interdisciplinary teams for documentation and discharge planning.
• Documents all utilization review activities in the system with payer communications and authorizations.
• Secures coverage approvals and coordinates peer-to-peer reviews when needed.
• Analyzes utilization trends to identify process improvements and resource optimization.

Skills

Utilization management

Medical necessity criteria

EHR proficiency

Communication & collaboration

HIPAA knowledge

Education

Associate Degree or higher in Nursing

Master's Degree in Social Work

Tools

Case management software

Electronic Health Records (EHR)

Job description

Community Health Systems is seeking a Clinical Utilization Review Specialist in the United States. The role evaluates the necessity and efficiency of healthcare services, conducting admissions reviews and supporting denials and appeals activities.

The position collaborates with physicians and interdisciplinary teams to secure documentation for medical necessity and discharge planning, ensuring alignment with payer requirements and utilization plans.