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Utilization Review Specialist
Cornerstone of RecoveryUtilization Review Specialist at Bradford Health Services analyzing medical records and treatment plans for compliance. Collaborating with healthcare providers to optimize patient outcomes and assess healthcare service necessity.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in utilization review and case management, with a strong foundation in medical terminology, clinical procedures, and healthcare regulations. Proficient in analyzing clinical documentation and coordinating with healthcare providers to ensure compliance with payer policies and best practices.
Highest-signal resume keywords
Utilization ReviewCase ManagementMedical TerminologyElectronic Health Records (EHR)Healthcare Regulations
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
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Hard Skills
Utilization ReviewCase ManagementMedical TerminologyClinical ProceduresHealthcare RegulationsInsurance Authorization ProcessesHealthcare Reimbursement ModelsAnalytical SkillsOrganizational SkillsCommunication Skills
Soft Skills
Analytical SkillsCommunication SkillsOrganizational Skills
Tools & Technologies
Electronic Health Records (EHR) SystemsUtilization Management Software
Certifications & Qualifications
Registered Nurse (RN) LicenseCertified Professional in Utilization ReviewCertified Case Manager
Industry Keywords
MedicareMedicaidManaged Care OrganizationsPayer-Specific Guidelines
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 Nursing, Health Administration, or a related healthcare 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.
- Preferred Qualifications: Registered Nurse (RN) license or equivalent clinical certification.
- Experience with electronic health records (EHR) systems and utilization management software.
- Certification in Utilization Review (e.g., Certified Professional in Utilization Review or Certified Case Manager).
- Prior experience working with managed care organizations or insurance companies.
- Advanced knowledge of Medicare, Medicaid, and other payer-specific guidelines.
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.