Utilization Management Clinical Specialist

Sheppard Pratt Careers; Towson (MD); On-site; USD 68,000 - 109,000; Full time

Benefits offered by this job

Tuition reimbursement

Comprehensive medical, dental and vis​

403b retirement match

Generous paid time off

Employee Assistance Program (EAP)

Job summary

Sheppard Pratt seeks a qualified utilization management professional to provide timely reviews for behavioral health services in Towson, MD. You will coordinate with Medicare, Medicaid, and payer requirements, conduct medical reviews for inpatient and partial hospitalization programs, and document findings across hospital data systems.

You will lead appeals with data-driven analysis to support medical necessity decisions, collaborating with internal stakeholders and external agencies.

Qualifications

• Requires RN license or clinical license (LCPC or LCSW-C).
• Experience in utilization management or behavioral health.
• Knowledge of payer requirements and clinical criteria.

Responsibilities

• Provides timely utilization reviews for behavioral health services.
• Conducts medical reviews for inpatient and partial hospitalization programs and documents in hospital systems.
• Coordinates with Medicare, Medicaid, and commercial payers to ensure CMS and payer requirements.
• Leads appeals process through data-driven analysis to support medical necessity decisions.

Skills

Utilization management

Behavioral health

Payer knowledge

Documentation

Education

RN license

LCPC license

LCSW-C

Job description

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Locations

Showing 1 location

Hospital - Towson
Towson, MD 21204, USA

• On-site
• Salary Range : $67,999.78 USD to $108,576.83 USD
• Nursing
• Full-Time
• Requisition #: UTILI012940

Description

What to expect:

• Provides timely, comprehensive utilization reviews for behavioral health services for Sheppard Pratt patients.
• Conducts medical reviews for inpatient and partial hospitalization programs, maintains accurate documentation within hospital data systems, and communicates effectively with internal stakeholders and external agencies.
• Coordinates with Medicare, Medicaid, and Commercial Health Plans to ensure compliance with CMS (Centers for Medicare & Medicaid Services), Maryland Medicaid, and payer-specific requirements.
• Leads the appeals process through data-driven analysis, optimized workflows, and strengthened clinical documentation to support medical necessity decisions and successful appeal outcomes.

What you’ll get from Us:

At Sheppard Pratt, you will work alongside a multi-disciplined team led by a bold vision to change lives. We offer:

• A commitment toprofessional development,includinga comprehensive tuition reimbursement program tosupport ongoing education and licensure and/or certification preparation
• Comprehensive medical, dental and vision benefitsfor benefit eligible positions
• 403b retirement match
• Generous paid-time-offfor benefit eligible positions
• Complimentary Employee Assistance Program (EAP)

Pay for this position is determined ona number offactors, including but not limited to,yearsand levelof related experience.

What we need from You:

• Associate or Bachelor’sdegree in nursing,Bachelor’s orMaster’sdegree inClinical Counseling,Healthcare Administration, or related clinical field.
• Active RN license, Licensed Clinical Professional Counselor(LCPC), or Licensed Certified Social Worker-Clinical (LCSW-C).
• Minimum of 3-5 years of experience inutilizationmanagement,orbehavioral health.
• Strong knowledge of payer requirements, clinicalcriteriaand behavioral health diagnosis.

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Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.