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Utilization Review Specialist

Post Date:
Service Area:
The HSC Pediatric Center

Job Requirements

Responsible for the clinical review of pediatric and young adult members for all inpatient medical stays, inpatient rehabilitative therapy, and long term care services based on standardized criteria. Responsible for both the management of resources and the achievement of desired outcomes for patients with ongoing communication to the Manager of Collaborative Services, the Medical Director and team staff for the development and coordination of the discharge plan and continued medical management of patients.  


Essential job duties:  

1. Ensures compliance with standard guidelines, policy and procedures and updates for utilization review and care management. 

2. Organizes utilization management caseload based on daily volume, number of telephone reviews, and complexity of individual case management processes. 

3. Performs review after admission to determine medical necessity and appropriateness of care. 

4. Utilizes HSC criteria to validate medical necessity for admission and continued stay, including the appropriateness of treatment and the use of discharge screens. Evaluates the appropriate quality of care including length of stay and alternative levels of care needed health care services. 

5. Identifies and reports quality or utilization issues to medical director or their designee. 

6. Demonstrates the ability to exercise independent judgment, along with reference materials, when performing certification. 

7. Utilizes a case conceptual framework to assess and determine the viability of plan of care based on safety risk factors, community standards of practice, resource allocations and hospital policies and procedures. 

8. Integrates the UR process hospital wide through the coordination of communication processes with physician, treatment team, and other staff members of the facility. 

9. Actively contributes as a team member to utilization of resources within the department. 

10. Conducts retrospective reviews for medical necessity and continued stay. 

11. Conducts prospective reviews for medical necessity. 

12. Determines the level of care and assesses patient’s clinical readiness for transfer and or discharge to the next appropriate level of care; utilizes knowledge of reimbursement and managed care in decision-making. 

13. Assist the physicians in proper placement of patients in services based upon HSC criteria. 

14. Acts as patient advocate/liaison with staff/payers/patient/family and community agencies to facilitate problem solving and coordinate services. 

15. Assesses patient insurance benefits. Coordinates with providers, as appropriate. 

16. Maintains current knowledge of laws, regulations, and interpretations of utilization review, Medicaid, commercial insurance. 

17. Ensures that all insurance eligibility information is accurate and benefits are verified. All information is accurately entered in to the computer system. 

18. Communicates verification/certification problems to the physicians and or office staff and other appropriate hospital departments. 

19. Provide statistical monitoring as required for department accountability and performance improvement processes. 

20. Communicates insurance information affecting the discharge plan to Case Managers. 

21. Assists leadership in designing, developing and implementing the UM program to meet the needs of the special needs population. 

22. Recognizes and reports problems, issues, and/or discrepancies with procedures and/or patients medical records to the appropriate manager for clarification and/or follow-up. 

23. Participates in department meetings with positive and constructive input. 

24. Maintains required records in an organized manner and provides reports upon request and/or as scheduled. 

25. Assists with orientations, cross training, and skill development of staff members as scheduled and fills-in for other department functions as needed  

Other job duties: 

1. May perform other duties in addition to those outlined in this job description.     



Required Experience:

One year experience in utilization management. 3-5 years of clinical experience, pediatric experience preferred.   



RN in the District of Columbia; CCM certification preferred    


Required Education:

Bachelor’s degree preferred

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