Utilization Review Clinician

The Utilization Review Clinician is responsible for conducting timely reviews of requests for post-acute services, determining the appropriateness of requested services based on clinical guidelines and coverage limitations. They will comply with all standard operating procedures and organizational policies, develop relationships with healthcare providers and customers to improve health outcomes, and apply clinical knowledge for care coordination. The clinician will consult with peer reviewers and Medical Directors to ensure medically appropriate, quality, and cost-effective care. Key duties include performing prior authorization and continued stay reviews, approving services in compliance with health plan guidelines, collaborating with case managers and physicians for appropriate care levels, and participating in team meetings and educational activities. They will also ensure compliance with federal, state, and accreditation standards, support payer programs, make benefit determinations, coordinate benefits and transitions, and utilize knowledge of healthcare system resources. Other job duties as assigned will also be performed.