WHAT IS AN utilization review specialist jobs
An utilization review specialist, also known as a utilization management specialist, is a healthcare professional who plays a crucial role in ensuring the efficient and appropriate use of medical resources. These specialists work within healthcare organizations, insurance companies, and government agencies to review medical records and treatment plans to determine the necessity and appropriateness of healthcare services. By evaluating the medical necessity of procedures, treatments, and hospital stays, utilization review specialists help contain costs, improve patient outcomes, and ensure that healthcare resources are used effectively.
WHAT USUALLY DO IN THIS POSITION
In this position, utilization review specialists have a range of responsibilities. They review medical records, treatment plans, and clinical documentation to assess the necessity and appropriateness of healthcare services. This involves analyzing medical codes, such as ICD-10 and CPT codes, to ensure accurate billing and proper utilization of resources. Utilization review specialists also collaborate with healthcare providers, insurance companies, and other stakeholders to gather additional information and clarify medical documentation.
Furthermore, utilization review specialists play a crucial role in the prior authorization process. They review requests for medical services, procedures, or treatments to determine if they meet the necessary criteria for coverage and reimbursement. This involves understanding insurance policies, medical guidelines, and industry standards to make informed decisions.
Communication is a key aspect of the role, as utilization review specialists often need to interact with healthcare providers, patients, and insurance companies. They may need to explain coverage decisions, provide guidance on alternative treatment options, and facilitate appeals or grievances.
TOP 5 SKILLS FOR POSITION
- Strong analytical skills: Utilization review specialists need to analyze medical records, treatment plans, and clinical documentation to make informed decisions. They should have the ability to interpret complex information and identify any discrepancies or inconsistencies.
- Knowledge of medical coding: A strong understanding of medical coding systems, such as ICD-10 and CPT codes, is essential for utilization review specialists. This knowledge enables them to accurately assess medical records and ensure proper billing and utilization of resources.
- Familiarity with healthcare guidelines and policies: Utilization review specialists need to be well-versed in healthcare guidelines, policies, and regulations. This includes knowledge of insurance coverage criteria, medical necessity criteria, and industry standards.
- Excellent communication skills: Effective communication is crucial in this role. Utilization review specialists need to communicate with healthcare providers, insurance companies, and patients to gather information, explain coverage decisions, and provide guidance on alternative treatment options.
- Attention to detail: Utilization review specialists must have a keen eye for detail to identify any errors or inconsistencies in medical records and treatment plans. They need to ensure accuracy and compliance with regulatory requirements.
HOW TO BECOME THIS TYPE OF SPECIALIST
To become an utilization review specialist, certain steps can be followed. The first step is to obtain a bachelor's degree in a related field, such as healthcare administration, nursing, or medical coding. This provides a solid foundation in healthcare principles, medical terminology, and healthcare regulations.
After completing a bachelor's degree, gaining practical experience in the healthcare field is beneficial. This can be achieved through internships, entry-level positions, or volunteer work in healthcare organizations or insurance companies. This experience helps develop an understanding of the healthcare industry and the utilization review process.
Obtaining relevant certifications can also enhance career prospects in this field. The American Board of Quality Assurance and Utilization Review Physicians offers the Certified Professional in Utilization Review/Management (CPUR) certification, which demonstrates expertise in utilization review and management. Additionally, the American Nurses Credentialing Center offers the Nurse Executive-Board Certified (NE-BC) certification for nurses interested in specializing in utilization review.
Continuing education and staying updated with industry developments is essential for utilization review specialists. Attending workshops, conferences, and seminars can provide valuable insights into changes in healthcare policies, regulations, and best practices.
AVERAGE SALARY
The average salary for utilization review specialists can vary depending on factors such as experience, location, and the employing organization. According to data from the Bureau of Labor Statistics, the median annual wage for medical and health services managers, which includes utilization review specialists, was $104,280 as of May 2020. However, it is important to note that salaries can range from around $60,000 to over $150,000 depending on various factors.
ROLES AND TYPES
Utilization review specialists can work in various settings within the healthcare industry. Some common roles and types include:
- Hospital utilization review specialists: These specialists work within hospitals and healthcare systems to review medical records, treatment plans, and clinical documentation. They ensure the appropriate utilization of resources and adherence to insurance coverage criteria.
- Insurance utilization review specialists: These specialists work for insurance companies and play a crucial role in the prior authorization process. They review requests for medical services, procedures, or treatments to determine if they meet the necessary criteria for coverage and reimbursement.
- Government agency utilization review specialists: These specialists work for government agencies, such as Medicare or Medicaid, to review medical records and treatment plans for compliance with program guidelines. They help ensure that taxpayer-funded healthcare resources are used appropriately.
- Independent utilization review specialists: Some utilization review specialists work on an independent or consulting basis. They may be contracted by healthcare organizations, insurance companies, or legal firms to provide expert opinions and review medical records for legal or reimbursement purposes.
LOCATIONS WITH THE MOST POPULAR JOBS IN USA
Utilization review specialist jobs can be found throughout the United States, but certain locations have a higher concentration of opportunities. Some of the locations with the most popular jobs in this field include:
- New York, NY: With a large healthcare industry and numerous insurance companies, New York offers many job opportunities for utilization review specialists.
- Los Angeles, CA: The healthcare industry in Los Angeles is vast, providing numerous job opportunities for utilization review specialists.
- Chicago, IL: Chicago has a thriving healthcare sector, including hospitals, insurance companies, and government agencies, which creates a demand for utilization review specialists.
- Houston, TX: Houston is home to several major healthcare institutions and insurance companies, making it a hub for utilization review specialist jobs.
- Atlanta, GA: Atlanta has a strong healthcare industry, with many hospitals, insurance companies, and government agencies, providing ample job opportunities for utilization review specialists.
WHAT ARE THE TYPICAL TOOLS
Utilization review specialists utilize various tools and software to perform their duties effectively. Some of the typical tools used in this role include:
- Electronic Health Record (EHR) systems: Utilization review specialists often work with EHR systems to access and review medical records, treatment plans, and clinical documentation.
- Medical coding software: This software helps utilization review specialists analyze medical codes, such as ICD-10 and CPT codes, for accurate billing and utilization assessment.
- Utilization review software: Specialized software designed for utilization review helps streamline the review process, track cases, and generate reports.
- Communication tools: Utilization review specialists use various communication tools, such as email, phone systems, and video conferencing platforms, to interact with healthcare providers, insurance companies, and other stakeholders.
- Reference materials: Utilization review specialists may refer to medical guidelines, insurance policies, and industry standards to ensure compliance and make informed decisions.
IN CONCLUSION
Utilization review specialists play a crucial role in the healthcare industry by ensuring the efficient and appropriate use of medical resources. With their analytical skills, knowledge of medical coding, and familiarity with healthcare guidelines, they review medical records and treatment plans to determine the necessity and appropriateness of healthcare services. By working collaboratively with healthcare providers, insurance companies, and other stakeholders, utilization review specialists help contain costs, improve patient outcomes, and ensure the effective utilization of healthcare resources. With the right education, experience, and certifications, individuals can pursue a rewarding career in this field and make a positive impact on the healthcare system.