Utilization Management Specialist

We are seeking a motivated and detail-oriented Utilization Management Specialist to join our team. In this role, you will play a crucial part in reviewing medical information to ensure the necessity of healthcare services and adherence to best practices. Your responsibilities will include supporting the approval of cost-effective healthcare services that align with patient needs. You will be tasked with reviewing outpatient procedures, inpatient admissions, home health, and behavioral health services to determine their necessity. Collaborating with providers and medical directors to obtain prior authorization and plan case reviews when necessary will be an essential aspect of your role. Additionally, working closely with clinical staff to guarantee appropriate care and resource utilization is vital. As a Utilization Management Specialist, you will actively participate in quality improvement projects and contribute to the development of clinical guidelines. Monitoring and reporting on utilization trends to management will be a key responsibility to ensure efficient healthcare service delivery. Preferred Skills for this role include familiarity with MCG/Inter Qual Guidelines, up-to-date knowledge of regulations, and maintaining well-organized records of all activities. Experience with Medicaid, Medicare, and Managed Care is advantageous, along with a strong understanding of anatomy, physiology, and medical terminology. Proficiency in MS Office applications, excellent communication skills for effective teamwork, and the ability to work both independently and collaboratively are essential. Strong analytical and problem-solving skills are also desirable. Candidates applying for this position should hold a Bachelor's Degree in Nursing, while freshers are encouraged to apply. Previous work experience in the Hospital Field is considered an added advantage. Benefits offered for this position include a five-day workweek, with fixed weekends off (Saturday and Sunday). Employees working on weekends are eligible for double wages, and a two-way cab facility is available for night shifts.,