Clinical Utilization Specialist

Job Overview
We are seeking a dynamic and detail-oriented Clinical Utilization Specialist to join our healthcare team. In this vital role, you will be responsible for optimizing patient care through comprehensive utilization review, medical documentation review, and case management activities. Your expertise will support clinical decision-making, ensure compliance with healthcare standards, and facilitate efficient resource utilization across inpatient, outpatient, and specialized care settings. This position offers an exciting opportunity to impact patient outcomes positively while working within a collaborative, fast-paced environment dedicated to excellence in healthcare delivery.

Responsibilities

• Conduct thorough utilization reviews for inpatient and outpatient cases, ensuring appropriate level of care based on clinical documentation and established criteria such as NCQA standards and CMS guidelines.
• Review medical records, clinical documentation, and coding (ICD-9, ICD-10, CPT) to verify accuracy, completeness, and compliance with HIPAA regulations.
• Collaborate with physicians, nurses, case managers, and other healthcare professionals to facilitate discharge planning and coordinate patient care transitions across settings such as hospitals, nursing homes, hospice care, or home health agencies.
• Utilize EMR (Electronic Medical Record) systems like Cerner, Epic, Athenahealth, or eClinicalWorks to document findings and support medical management decisions.
• Perform medical coding tasks including ICD coding and DRG assignment to support billing processes and ensure proper reimbursement.
• Participate in clinical documentation improvement initiatives to enhance the accuracy of medical records and optimize reimbursement while maintaining compliance with accreditation standards like NCQA.
• Support utilization management activities by analyzing patient data related to ICU experience, trauma center criteria (Level I & II), pediatrics (PICU), emergency medicine, or primary care cases to promote appropriate resource use.

Requirements

• Proven experience in managed care environments with a strong understanding of Medicare, Medicaid, or commercial insurance protocols.
• LMSW (preferred) Master- Level Non licensed will be considered based off prior experience.
• Critical care experience in settings such as ICU or trauma centers is highly desirable.
• Knowledge of medical terminology, anatomy, physiology, and clinical documentation practices is essential.
• Familiarity with EMR/EHR systems including Cerner, Epic, Athenahealth or similar platforms is required.
• Experience with medical coding (ICD-9/10, CPT), DRG assignment, and utilization review processes is necessary.
• Strong background in hospital or outpatient clinic settings; nursing home or hospice care experience is a plus.
• Ability to interpret complex medical records and ensure compliance with HIPAA regulations.
• Excellent communication skills for collaborating with multidisciplinary teams and explaining clinical findings clearly.
• Certifications such as CCM (Case Management Certification), RHIT/RHIA (Registered Health Information Technician/Administrator), or equivalent are preferred. Join our team to make a meaningful difference in patient care through expert utilization management! We value proactive professionals who thrive in collaborative environments dedicated to healthcare excellence and continuous improvement.

Pay: $20.00 - $28.00 per hour

Work Location: Hybrid remote in Columbia, SC 29223