Utilization Management Specialist

Job Description

Role & responsibilities We are seeking a dedicated Utilization Management Specialist to join our Chennai office. In this role, you will be responsible for reviewing and analyzing clinical information to determine the medical necessity and appropriateness of healthcare services, ensuring compliance with established guidelines and policies. Your expertise will contribute to optimizing patient care and resource utilization. Key Responsibilities Conduct prior authorization, concurrent, and retrospective reviews for various healthcare services, including inpatient, outpatient, home health, and behavioral health. Apply evidence-based criteria (e.g., MCG, InterQual) to assess the necessity of medical services. Collaborate with healthcare providers, medical directors, and clinical staff to facilitate appropriate care plans and resource utilization. Maintain accurate and organized documentation of all utilization management activities. Participate in quality improvement initiatives and assist in developing clinical guidelines. Monitor and report on utilization trends to management, identifying areas for improvement. Educational qualifications and Experience : Bachelor's Degree in Nursing (BSc Nursing) or equivalent. Minimum of 2 years of clinical experience in a hospital or healthcare setting. Active and unrestricted Registered Nurse (RN) license in the United States. Familiarity with utilization management processes and guidelines (e.g., MCG, InterQual). Proficient in medical terminology, anatomy, and physiology. Strong analytical and problem-solving skills. Excellent communication skills, both written and verbal. Proficient in Microsoft Office applications. Preferred candidate profile Preferred Qualifications Experience with Medicaid, Medicare, and Managed Care programs. Previous experience in utilization review or case management. Certification in Case Management (CCM) or Accredited Case Manager (ACM) is a plus