Specialist Utilization Review & Authorization at St. Clair Hospital – Pittsburgh, Pennsylvania

Summary

The role of a Utilization Review and Authorization Specialist is to ensure medical necessity, appropriateness of healthcare services for patients requiring Inpatient and Outpatient procedures along with proper review of submission and response from the patient’s insurance company. They review and analyze medical records, insurance authorization requirements, CPT coding appropriate to the intended procedure.

Minimum Qualifications

1. Current licensure as a Registered Nurse in Pennsylvania.
2. Minimum of 5 years of clinical nursing experience
3. 3-4 years of experience in Utilization Review or associated field
4. Strong knowledge of healthcare delivery systems and utilization management practices
5. Excellent communication skills, including the ability to communicate complex medical information, insurance guidelines and appropriate level of care to Physician and/or care team
6. Ability to work independently and as part of a team in a fast-paced environment
7. Proficient computer skills and experience with electronic health records and payer portal applications
8. Knowledge of procedural and surgical CPT and correlating ICD-10 codes

Preferred Qualifications

1. Bachelor's degree in nursing or health related field.