Utilization Review Specialist

The UR Specialist reviews and monitors patients’ utilization of health care services with the goal of maintaining high quality, cost-effective care. The duties include providing the medical and utilization expertise necessary to evaluate the appropriateness and efficiency of medical services and procedures.
Performs concurrent and retrospective reviews on all patients. Monitors level and quality of care.
Responsible for the proactive management of patients with the objective of improving quality outcomes and decreasing costs.
Evaluates and provides feedback to treating physicians regarding a patient’s discharge plans and available covered services, including identifying alternative levels of care that may be covered.
Monitors all utilization reports to assure compliance with reporting and turnaround times.
Addresses care issues with the Director of Clinical Services and Chief Medical Officer/Medical Director as appropriate.
Coordinates an interdisciplinary approach to support continuity of care.
Provides utilization management, transfer coordination, discharge planning, and issuance of all appropriate authorization for covered services as needed.
Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum.
Clarifies health plan medical benefits, policies and procedures for members, physicians, staff, contract providers, and outside agencies.
Requirements
Requirements
Bachelor's degree in Social Work or related field required.
Clinical Licensure in the State of Nevada preferred, no required
Knowledge of medical terminology, medical records, and appropriate medical coding system.
Working knowledge with software and/or equipment (Microsoft Office applications including Outlook, Word, Excel and PowerPoint).
Maintains confidentiality of patients at all times.
Benefits
We proudly offer the following benefits available first of the month following just one month of employment:
Competitive rates
Flexible schedules
Tuition reimbursement
Comprehensive package of benefits to include:
Medical
Dental
Vision
Life, Pet, Identity Theft Insurance
401k
Generous paid time off
Short Term and Long Term Disability