Utilization Review Specialist

We are looking for a detailed-oriented Utilization Review (UR) Specialist to help us maximize patient care quality and ensure seamless insurance operations.

The UR Specialist evaluates patient medical records to ensure treatments meet clinical necessity and regulatory standards. You will serve as the primary bridge between our medical staff and insurance providers, facilitating timely care approvals and minimizing claim denials.

Other responsibilities include retrieving discharge documents on a daily basis from charts, faxing when applicable, and retrieving authorizations.

KEY RESPONSIBILITIES:

• Evaluate outpatient charts against established clinical criteria.
• Submit and track insurance authorization requests.
• Draft and submit clinical appeals for denied services.
• Communicate directly with insurance medical directors and case managers.
• Advise physicians and clinical staff on documentation requirements.
• Monitor utilization trends, denial rates, and approval timelines.
• Ensure adherence to Medicare, Medicaid, and private payer guidelines.
• Hours are Monday - Friday from 8:00am - 4:30pm

Requirements

• Current LPN, RN or other Clinical Licensure and/or master’s degree required.
• Minimum two (2) years of clinical experience, with 1+ years in utilization review or case management required
• Knowledge of Nevada Pa