Utilization Review Specialist

Job Summary
We are seeking a highly skilled and detail-oriented Utilization Review Specialist to join our healthcare team. The ideal candidate will be responsible for evaluating medical records, clinical documentation, and patient care plans to ensure appropriate utilization of healthcare services in compliance with regulatory standards such as HIPAA. This role involves collaborating with healthcare providers across inpatient, and specialized settings including detoxification and residential. Proficiency in medical coding systems such as CPT, ICD-9, ICD-10, and DRG is essential, along with experience using EMR/EHR systems like Epic, Cerner, and KIPU. The Utilization Review Specialist plays a critical role in supporting clinical documentation improvement, discharge planning, case management, and ensuring adherence to managed care protocols.

Responsibilities

• Conduct comprehensive reviews of medical documentation to assess the necessity and appropriateness of services provided.
• Evaluate patient records for compliance with clinical standards and regulatory requirements including Medicare, JACHO standards, and sub-acute inpatient-specific protocols.
• Utilize clinical knowledge of physiology, substance abuse, mental health and co-occurring disorders, nursing practices, and medical terminology to interpret complex health information.
• Apply coding expertise (ICD-9/10, CPT) to support accurate documentation review and case management processes.
• Collaborate with multidisciplinary teams to facilitate discharge planning, hospice care coordination, and outpatient or inpatient case management.
• Ensure all reviews are documented thoroughly within EMR/EHR systems such as Epic or KIPU while maintaining HIPAA compliance.
• Support clinical documentation improvement initiatives by identifying gaps in records and recommending necessary updates.
• Participate in quality assurance activities related to utilization management and ensure adherence to accreditation standards such as Jacho.
• Stay current on healthcare regulations affecting utilization review processes including managed care policies and hospital accreditation requirements.

Qualifications

• Proven experience in utilization review or utilization management within sub-acute care settings such as Detox and residential level of care.
• Strong background in managed care environments with familiarity in Medicare regulations and health information management practices.
• Proficiency with EMR/EHR systems including KIPU, eClinicalWorks; experience with medical coding (ICD-9/10, CPT) is a plus.
• Knowledge of clinical documentation improvement strategies and familiarity with DRG assignment processes.
• Experience working in inpatient detox and residential experience is a plus.
• Excellent understanding of medical terminology, anatomy, physiology, and patient care procedures across various specialties including mental health and substance abuse.
• Ability to interpret complex medical records accurately while ensuring compliance with HIPAA standards.
• Strong analytical skills with attention to detail; effective communication skills for collaboration across multidisciplinary teams. This position offers an opportunity to contribute significantly to healthcare quality assurance while working within a dynamic team dedicated to patient-centered care excellence.

Pay: From $23.16 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Work Location: Hybrid remote in Miramar, FL 33025