Hospital Utilization Review Specialist

About the role

The Hospital Utilization Review Specialist evaluates clinical records and hospital facilities to ensure appropriate use of services. The role involves concurrent and retrospective reviews, collaboration with case management and condition management teams, and adherence to clinical guidelines and regulatory standards.

Key responsibilities

• Visit hospitals and health facilities to assess utilization using clinical guidelines and procedures.
• Perform daily audit entries and verify closed cases in electronic systems.
• Evaluate justification of services provided and flag irregular utilization patterns.
• Identify and report cases with potential risks to case management, condition management, or extended stays.
• Suggest care alternatives to providers and coordinate patient discharge plans.
• Participate in special projects assigned to the Clinical Affairs department.
• Ensure compliance with Clinical Affairs standards and CMS guidelines.

Required profile

• Bachelor’s Degree in Nursing.
• At least one year of experience reviewing hospital utilization, preferably in health insurance.
• Valid nursing license from the Association of Nursing Professionals of Puerto Rico.
• Valid driver’s license in the Commonwealth of Puerto Rico.
• Advanced proficiency in Spanish (comprehensive, writing and verbal).
• Advanced proficiency in English (comprehensive, writing and verbal).