Utilization Review Specialist - Elevate Care

Bradford Health Services; Lucedale (MS); On-site; USD 65,000 - 90,000; Full time

Job summary

Bradford Health Services is seeking a dedicated Utilization Review Specialist to evaluate medical records, treatment plans, and clinical data to determine the necessity and appropriateness of care.

The role collaborates with providers, insurers, and case managers to secure timely approvals, ensure regulatory compliance, and optimize patient outcomes while supporting cost-effective care delivery across the United States.

Qualifications

• Bachelor’s degree in Nursing, Health Administration, or related healthcare field.
• At least 2 years in utilization review, case management, or clinical healthcare roles.
• Strong knowledge of medical terminology, clinical procedures, and healthcare regulations.
• Familiarity with insurance authorization processes and utilization management guidelines.
• Excellent communication and analytical skills with attention to detail.

Responsibilities

• Review and analyze medical records, treatment plans, and clinical documentation to assess the necessity and appropriateness of healthcare services.
• Coordinate with healthcare providers, insurance representatives, and case managers to obtain additional information and clarify treatment details.
• Make informed decisions regarding authorization, continuation, or denial of services based on clinical guidelines, policies, and regulatory requirements.
• Document findings and decisions accurately in electronic health record systems and prepare detailed reports for internal and external stakeholders.
• Stay current with healthcare regulations, insurance policies, and clinical best practices to ensure compliance and effective utilization management.

Skills

Communication skills

Analytical skills

Medical terminology

Regulatory knowledge

Attention to detail

EHR proficiency

Utilization review software

Education

Bachelor's degree in Nursing/Health Administration/related field

RN license (preferred)

Utilization Review certification (preferred)

Tools

Electronic Health Records (EHR)

Utilization review software

Job description

Bradford Health Services is seeking a dedicated Utilization Review Specialist to evaluate medical records, treatment plans, and clinical data to determine the necessity and appropriateness of care.

The role collaborates with providers, insurers, and case managers to secure timely approvals, ensure regulatory compliance, and optimize patient outcomes while supporting cost-effective care delivery across the United States.