Utilization Management Clinical Specialist

Socket.dev; Towson (MD); On-site; USD 85,000 - 110,000; Full time

Benefits offered by this job

Tuition reimbursement

Medical benefits

403b retirement match

PTO

EAP program

Mileage reimbursement

Job summary

Sheppard Pratt in Towson, MD is seeking an experienced utilization management professional to provide timely reviews for behavioral health services, coordinate with hospital programs, and communicate with internal and external stakeholders.

The role focuses on ensuring medical necessity, payer compliance, and leading appeals through data-driven analysis while supporting collaboration across multidisciplinary teams.

Qualifications

• Active RN license, LCPC, or LCSW-C licensure.
• Minimum of 3–5 years of utilization management or behavioral health experience.
• Strong knowledge of payer requirements, clinical criteria, and behavioral health diagnosis.

Responsibilities

• 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.

Education

Associate or Bachelor’s degree in nursing

Bachelor’s or Master’s degree in Clinical Counseling, Healthcare Administration, or related clinical field

Job 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)

• Generous mileage reimbursement program

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.