Utilization Review Specialist

The Wellstone Group; North Little Rock (AR); On-site; USD 52,000 - 75,000; Full time

Job summary

The Wellstone Group in North Little Rock, AR is seeking an experienced Utilization Review Specialist. This on-site role focuses on reviewing patient care plans, coordinating with interdisciplinary teams, and ensuring regulatory compliance in a fast-paced office environment.

You will manage admissions/discharges, process authorizations, and participate in quality initiatives to improve patient outcomes and efficiency. A valid COTA or PTA license and managed care understanding are required.

Qualifications

• Long-term care experience required.
• Active COTA or PTA license.
• Minimum 1 year of experience in MDS, COTA, PTA, or related field, preferably in a managed care setting.
• Strong understanding of managed care principles and clinical guidelines.
• Ability to handle a high caseload with excellent organizational skills.
• Experience or willingness to learn systems such as PCC, Care Auth, Net Health, Availity, and Home & Community Services.
• Proficient in Microsoft Excel, Outlook, PDFs, and web-based platforms.

Responsibilities

• Review and Update Records: Ensure patient records and care plans are accurate before submission to insurance providers.
• Admissions & Discharges: Verify documentation for new admissions and discharges is complete and timely.
• Daily Workflow: Prepare due lists, send update notifications, and follow up on pending authorizations.
• Utilization Review: Conduct pre-authorizations and concurrent reviews to confirm the necessity and appropriateness of care.
• Collaboration: Partner with providers, case managers, and other healthcare professionals to support effective care planning.
• Compliance: Maintain adherence to state, federal, and organizational guidelines.
• Appeals Management: Review and respond to appeals related to utilization decisions.
• Quality Initiatives: Participate in projects aimed at improving patient outcomes and operational efficiency.

Skills

Managed care understanding

Organization skills

Excel & Office tools

Communication & problem-solving

Tools

PCC

Care Auth

Net Health

Availity

Home & Community Services

Job description

Utilization Review Specialist – North Little Rock, AR (72113)

Are you an experienced healthcare professional looking for an opportunity to make a difference in patient care management? We’re seeking a Utilization Review Specialist to join our team in North Little Rock, AR, helping ensure effective resource use while maintaining high-quality care within a managed care system.

About the Role:

This position plays a key role in reviewing patient care plans, collaborating with interdisciplinary teams, and ensuring compliance with insurance and regulatory requirements. The right candidate will be detail-oriented, organized, and able to manage multiple priorities in a fast-paced, office-based environment.

Key Responsibilities:

• Review and Update Records: Ensure patient records and care plans are accurate before submission to insurance providers.

• Admissions & Discharges: Verify documentation for new admissions and discharges is complete and timely.

• Daily Workflow: Prepare due lists, send update notifications, and follow up on pending authorizations.

• Utilization Review: Conduct pre-authorizations and concurrent reviews to confirm the necessity and appropriateness of care.

• Collaboration: Partner with providers, case managers, and other healthcare professionals to support effective care planning.

• Compliance: Maintain adherence to state, federal, and organizational guidelines.

• Appeals Management: Review and respond to appeals related to utilization decisions.

• Quality Initiatives: Participate in projects aimed at improving patient outcomes and operational efficiency.

Qualifications:

• Long-term care experience required

• Active COTA or PTA license

• Minimum 1 year of experience in MDS, COTA, PTA, or related field, preferably in a managed care setting

• Strong understanding of managed care principles and clinical guidelines

• Ability to handle a high caseload with excellent organizational skills

• Experience or willingness to learn systems such as PCC, Care Auth, Net Health, Availity, and Home & Community services

• Proficient in Microsoft Excel, Outlook, PDFs, and web-based platforms

Preferred Skills:

• Experience with Electronic Health Record (EHR) systems

• Strong multitasking abilities in a high-volume office setting

• Effective communication and problem-solving skills

Work Environment:

• On-site position at our North Little Rock, AR office

• Fast-paced, team-oriented environment requiring strong time management and attention to detail

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