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Key Responsibilities and Required Skills for Utilization Review Specialist

💰 $ - $

🎯 Role Definition

We are seeking a detail-oriented Utilization Review Specialist responsible for timely, accurate clinical review and utilization management (UM) decisions across inpatient, outpatient, and post-acute care settings. The ideal candidate applies evidence-based guidelines (InterQual/MCG/Care Guidelines), clinical judgment, and payer policy to determine medical necessity, issue authorizations or denials, manage appeals and case coordination, and support quality and regulatory compliance. This role regularly interfaces with providers, case managers, clinical leadership, and payers to optimize clinical outcomes, control cost of care, and ensure regulatory adherence.

📈 Career Progression

Typical Career Path

Entry Point From:

  • Registered Nurse (RN) — bedside or case management experience
  • Case Manager or Discharge Planner
  • Health Information/Utilization Coordinator

Advancement To:

  • Utilization Review Manager / Supervisor
  • Clinical Program Manager — Utilization Management or Case Management
  • Director of Utilization Management or Population Health
  • Medical Director, Utilization Management (for clinicians)

Lateral Moves:

  • Appeals & Denials Specialist
  • Clinical Documentation Improvement (CDI) Specialist
  • Provider Relations / Network Management
  • Prior Authorization Lead

Core Responsibilities

Primary Functions

  • Perform prospective, concurrent and retrospective utilization reviews to determine medical necessity, level of care, length of stay and appropriateness of care using evidence-based criteria (InterQual, MCG, internal clinical policies); document clinical rationale and adjudication in the UM system.
  • Triage and process prior authorization and referral requests for inpatient admissions, outpatient procedures, imaging, durable medical equipment (DME), and specialty services; issue authorizations, modifications, or denials within contractual and regulatory timeframes.
  • Review medical records, progress notes, nursing assessments, medication lists, laboratory and imaging results, operative reports and consult notes to synthesize clinical information and reach defensible clinical decisions.
  • Apply payer policies, benefit plans, case law and medical necessity criteria to determine coverage and to ensure consistency and compliance with NCQA, URAC, CMS and state regulatory requirements.
  • Communicate clinical decisions and rationale to treating physicians, clinic staff, case managers and members by phone, written notice or electronic message; conduct physician-to-physician (peer-to-peer) discussions when appropriate.
  • Initiate and coordinate discharge planning and transitions of care by collaborating with case management, social work, post-acute providers and community resources to promote safe, appropriate discharge and reduce avoidable readmissions.
  • Prepare and issue written denial letters, partial approvals, and appeal responses with clear clinical rationale and citations to policy/guidelines; ensure member and provider notification requirements are met.
  • Manage concurrent review workflows for inpatient and observation patients to monitor progress, document medical necessity for continued stay, and recommend alternatives (step-down, home health, rehabilitation).
  • Escalate complex or high-risk cases to senior clinical staff or medical directors for peer review, credentialed review or exceptions beyond scope of practice.
  • Participate in retrospective chart audits and focused reviews to monitor adherence to medical necessity determinations and to identify trends in denials, appeals and utilization.
  • Maintain accurate and auditable records in UM systems (e.g., Utilization Management Platform, EMR) including authorizations, denials, appeals, peer reviews and clinical notes for regulatory and internal quality reviews.
  • Apply clinical judgment to identify potential fraud, waste or abuse related to utilization patterns and report concerns to compliance or special investigations teams as required.
  • Tactfully manage provider and member escalations, providing education on benefits, documentation requirements, clinical criteria and appeals processes while maintaining compliance with HIPAA and regulatory standards.
  • Track utilization metrics (authorization turnaround time, denial rates, appeal overturns, length of stay impacts) and contribute to performance dashboards used by operations and clinical leadership.
  • Participate in multidisciplinary care conferences, utilization review committee meetings, and morning huddles to align utilization decisions with care plans and organizational goals.
  • Ensure continuous professional development by staying current with clinical practice updates, changes to InterQual/MCG criteria, payer policies and state/federal regulations affecting utilization management.
  • Coordinate complex case management activities such as high-cost care coordination, behavioral health integration, transplant evaluations, or specialty vendor referrals to ensure appropriate utilization and continuity of care.
  • Work closely with revenue cycle and authorization teams to validate pre-certification, address claim denials related to authorization or level of care, and support financial outcomes.
  • Provide accurate, timely responses to internal and external audits, regulatory inquiries, and accreditation surveys related to utilization review processes and documentation.
  • Support authorization workflows for telehealth, outpatient infusion, home health services, rehabilitation and skilled nursing facility placements, ensuring clinical appropriateness and continuity.
  • Use clinical data to identify opportunities for utilization improvement, cost containment and clinical program development (e.g., urgent care pathways, pre-authorization rules updates).
  • Participate in cross-functional implementation of new UM tools, electronic prior authorization systems, or EMR integrations; test workflows and provide clinical feedback.

Secondary Functions

  • Assist in the development, review and maintenance of utilization management policies, clinical decision trees, and provider education materials to support standardized UM practices.
  • Provide subject matter expertise and training to new UR staff, nurses transitioning into UM, or customer service teams on clinical criteria, documentation standards and appeals handling.
  • Support quality improvement initiatives by analyzing denial and appeal trends and recommending process improvements to decrease inappropriate variation in utilization decisions.
  • Aid in preparation of reports for clinical leadership and payer partners summarizing utilization trends, quality metrics and program impact.
  • Participate in community outreach and provider engagement programs to educate referring clinicians on appropriate admission criteria and pre-authorization best practices.
  • Support ad hoc data requests, collaborate with analytics teams to refine UM reporting, and help validate data used for operational decision-making.
  • Serve as backup support for member or provider phone lines during high-volume periods and help triage urgent clinical authorization needs.
  • Engage in peer review committees and review panels to support credentialed appeals and complex case adjudications.

Required Skills & Competencies

Hard Skills (Technical)

  • Clinical review using InterQual, MCG or similar evidence-based criteria for medical necessity determinations.
  • Prior authorization management for inpatient, outpatient, radiology, DME and specialty services.
  • Familiarity with payer policies, benefits interpretation, and contractual coverage rules.
  • Proficiency with electronic medical record systems (Epic, Cerner, Meditech) and UM/authorization platforms.
  • Strong clinical documentation and medical record abstraction skills for clear, auditable decision-making.
  • Experience preparing denial letters, appeal packages and supporting clinical evidence for overturn processes.
  • Knowledge of regulatory and accreditation requirements (URAC, NCQA, CMS, state Medicaid rules).
  • Ability to perform physician-to-physician peer reviews and present clinical rationale to providers.
  • Data literacy: ability to read utilization dashboards, interpret key performance indicators (TAT, denial rate, LOS) and produce basic reports.
  • Understanding of case management and discharge planning principles, post-acute care options and community resources.
  • Familiarity with behavioral health, complex chronic disease management and specialty networks (preferred).
  • Experience with telehealth authorization workflows and virtual care modalities (preferred).

Soft Skills

  • Excellent clinical judgment and decision-making with clear, concise written and verbal communication.
  • Strong stakeholder management: able to have difficult conversations with providers while maintaining professional rapport.
  • Detail-oriented with high standards for documentation, compliance and defensibility of decisions.
  • Time management and prioritization skills to manage high-volume authorization workflows and urgent requests.
  • Empathy and member-centered attitude when discussing care denials, appeals and alternative care options.
  • Collaboration and teamwork across clinical, operational and provider-facing teams.
  • Adaptability to changing guidelines, system changes and evolving payer policies.
  • Analytical mindset to identify trends and recommend process or policy improvements.
  • Conflict resolution and negotiation skills during peer-to-peer calls and appeals interactions.
  • Confidentiality and professional integrity in handling protected health information (PHI).

Education & Experience

Educational Background

Minimum Education:

  • Registered Nurse (RN) license OR Bachelor's degree in Nursing, Health Administration, Public Health, or related healthcare field; equivalent clinical experience may be acceptable.

Preferred Education:

  • Bachelor of Science in Nursing (BSN) or Master’s degree in Nursing, Health Administration, Public Health or Healthcare Management.
  • Certifications such as Certified Professional in Utilization Review (CPUR), Case Management Certification (CCM), or URAC/NCQA-related training are a plus.

Relevant Fields of Study:

  • Nursing (RN/BSN)
  • Health Administration / Healthcare Management
  • Public Health
  • Health Information Management / Informatics
  • Clinical specialties (e.g., Acute Care, Behavioral Health)

Experience Requirements

Typical Experience Range:

  • 1–5 years clinical experience with at least 1–2 years in utilization review, case management, prior authorization or managed care clinical operations.

Preferred:

  • 2–5+ years of utilization management experience in a health plan, hospital/acute care, specialty payer, or third-party UM vendor environment; demonstrated experience with InterQual/MCG, peer review, appeals handling, and regulatory compliance.
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