Utilization Review Specialist

Bradford Health Services

Utilization Review Specialist at Bradford Health Services ensuring medical necessity and compliance. Collaborating with providers and managing utilization review processes.

Posted 7/10/2026full-timeRemote • 🇺🇸 United StatesJuniorMid-LevelWebsite

About the role

Key responsibilities & impact

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, modification, or denial of services based on clinical guidelines and regulatory requirements.
Maintain accurate and detailed records of utilization review activities, decisions, and communications in compliance with organizational policies and legal standards.
Stay current with evolving healthcare regulations, payer policies, and clinical best practices to ensure consistent and compliant review processes.

Requirements

What you’ll need

Bachelor’s degree in a healthcare or related field.
At least 2 years of experience 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 healthcare reimbursement models.
Excellent analytical, communication, and organizational skills.

Benefits

Comp & perks

Medical Coverage – Three new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits.
Expanded Coverage – Options for domestic partners and a wider network of in-network providers.
Mental Health Support – Improved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching.
Voluntary Coverages – Pet insurance, home and auto insurance, family legal services, and more.
Student Loan Repayment – Available for nurses and therapists.
Retirement Benefits – 401(k) plan through Voya to help employees plan for the future.
Generous PTO – A robust paid time off policy to support work-life balance.
Voluntary Benefits for Part-Time Employees – Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week.

ATS Keywords

✓ Tailor your resume

Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools

Clinical Documentation AnalysisHealthcare Service AssessmentRegulatory ComplianceHealthcare Reimbursement ModelsDecision-Making in Authorization

Soft Skills

Analytical SkillsCommunication SkillsOrganizational Skills