Utilization Review Specialist — Care Optimization (On-site)

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

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.