Utilization Management Specialist

The Utilization Management Specialist (UMS) screens patients to determine the appropriate level of care through the use of clinical criteria, the Medicare Inpatient Only List, and individual payer requirements. The Utilization Management Specialist collects data, completes audits, and generates reports based on trends and various improvement initiatives. The Utilization Management Specialist interacts with Care Coordination, Coding, Revenue Integrity, Compliance, Physician Advisors, Physicians, and payers to establish level of care. The UMS actively participates in the physician Advisor program to assist in the correct LOC, and concurrent denials management. The position requires a completion of an accredited school of nursing program and a current Massachusetts RN licensure and registration. Two year’s experience in utilization review, case management, or relevant clinical experience is also needed.