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KP
Kemah Palms Recovery
Utilization Review Specialist
Career Insights for Clinical Auditor / Utilization Reviewer
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Scorecard
Based on Texas data
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What they do
A Clinical Auditor or Utilization Reviewer reviews the efficiency of healthcare delivery. Individuals tend to have had experience as a registered nurse or other healthcare delivery roles before transferring into this quality review role.
$94,930 / year median in Texas
-3% projected decline
Job Description
Responsibilities:
- Conduct utilization review of medical records to determine the appropriateness and necessity of healthcare services
- Evaluate medical documentation for accuracy, completeness, and compliance with regulatory guidelines
- Collaborate with healthcare providers to gather additional information or clarify documentation as needed
- Analyze medical data and make recommendations for treatment plans or alternative options
- Ensure that all utilization review activities are conducted in accordance with established policies and procedures
- Maintain accurate and detailed records of all utilization review activities
Experience:
- Minimum of 1 years of experience as a Utilization Review Nurse or similar role
- Strong knowledge of medical terminology, medical records, and medical office procedures
- Familiarity with insurance guidelines and reimbursement processes
- Excellent analytical and critical thinking skills
- Ability to work independently and make sound decisions based on clinical judgment
- Effective communication skills to interact with healthcare providers, patients, and insurance representatives Seeking an experienced Utilization Review Specialist with one year of experience capable of handling high volumes.
Pay:
$18.00- $25.