{"schemaVersion":"jobsearcher.job.v1","id":"1dc08beb85b2c014aa0e23d0","url":"https://jobsearcher.com/jobs/1dc08beb85b2c014aa0e23d0","canonicalUrl":"https://jobsearcher.com/jobs/1dc08beb85b2c014aa0e23d0","title":"Utilization Review Specialist","description":"If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.\n\nCorporate, Admin, Mgt. Full Time Office/Clerical Birmingham, AL, US\n\n2 days ago Requisition ID: 5974\n\nAbout Company\nWe’re officially a Great Place To Work®! We’ve always believed that supporting our team is just as important as supporting our patients. Now, we’re proud to share that we’ve earned Great Place To Work® Certification - based entirely on feedback from our own employees.\n\nThis certification reflects the culture we’ve worked hard to build - one rooted in trust, inclusion, and purpose-driven leadership.\n\nAt Bradford Health Services, we are committed to providing exceptional care to our patients while fostering a supportive and rewarding workplace for our employees. We believe that taking care of our team allows them to take better care of others, which is why we offer a comprehensive benefits package designed to support their well-being.\n\nOur benefits include:\n\nMedical Coverage\nThree new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits.\n\nExpanded Coverage\nOptions for domestic partners and a wider network of in-network providers.\n\nMental Health Support\nImproved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching.\n\nVoluntary Coverages\nPet insurance, home and auto insurance, family legal services, and more.\n\nStudent Loan Repayment\nAvailable for nurses and therapists.\n\nRetirement Benefits\n401(k) plan through Voya to help employees plan for the future.\n\nGenerous PTO\nA robust paid time off policy to support work-life balance.\n\nVoluntary Benefits for Part-Time Employees\nDental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week.\n\nAbout the Role\nThe Utilization Review Specialist plays a critical role in ensuring that healthcare services provided to patients are medically necessary, efficient, and compliant with regulatory standards. This position involves thorough evaluation of patient records, treatment plans, and clinical data to determine the appropriateness of care and resource utilization. The specialist collaborates closely with healthcare providers, insurance companies, and case managers to facilitate timely approvals and optimize patient outcomes. By applying clinical knowledge and regulatory guidelines, the role helps control healthcare costs while maintaining high-quality patient care. Ultimately, the Utilization Review Specialist contributes to the integrity and sustainability of healthcare delivery systems across the United States.\n\nMinimum Qualifications\n\nBachelor’s degree in a healthcare or related field.\n\nAt least 2 years of experience in utilization review, case management, or clinical healthcare roles.\n\nStrong knowledge of medical terminology, clinical procedures, and healthcare regulations.\n\nFamiliarity with insurance authorization processes and healthcare reimbursement models.\n\nExcellent analytical, communication, and organizational skills.\n\nPreferred Qualifications\n\nExperience with electronic health records (EHR) systems and utilization management software.\n\nCertification in Utilization Review (e.g., Certified Professional in Utilization Review or Certified Case Manager).\n\nPrior experience working with managed care organizations or insurance companies.\n\nAdvanced knowledge of Medicare, Medicaid, and other payer-specific guidelines.\n\nResponsibilities\n\nReview and analyze medical records, treatment plans, and clinical documentation to assess the necessity and appropriateness of healthcare services.\n\nCoordinate with healthcare providers, insurance representatives, and case managers to obtain additional information and clarify treatment details.\n\nMake informed decisions regarding authorization, continuation, modification, or denial of services based on clinical guidelines and regulatory requirements.\n\nMaintain accurate and detailed records of utilization review activities, decisions, and communications in compliance with organizational policies and legal standards.\n\nStay current with evolving healthcare regulations, payer policies, and clinical best practices to ensure consistent and compliant review processes.\n\nSkills\nThe Utilization Review Specialist applies clinical expertise and analytical skills daily to evaluate patient care plans against established medical criteria and payer policies. Effective communication skills are essential for collaborating with multidisciplinary teams, including physicians, nurses, and insurance representatives, to gather necessary information and explain review decisions. Organizational skills enable the specialist to manage multiple cases simultaneously while maintaining detailed documentation and meeting deadlines. Proficiency with healthcare IT systems supports efficient data retrieval and documentation of utilization review activities. Continuous learning and adaptability are important to stay updated on regulatory changes and evolving clinical standards, ensuring compliance and optimal patient care.\n\n#J-18808-Ljbffr","company":"Automatic Data Processing","rawCompany":"automatic data processing","city":"Lucedale","state":"MS","isRemote":false,"isActive":false,"createdAt":"2026-10-26T04:05:30.853Z","occupations":[{"code":"29-2072.00","title":"Medical Records Specialists","slug":"medical-records-specialists"},{"code":"11-9111.00","title":"Medical and Health Services Managers","slug":"medical-and-health-services-managers"},{"code":"29-9021.00","title":"Health Information Technologists and Medical Registrars","slug":"health-information-technologists-and-medical-registrars"}],"industries":[{"code":"622110","title":"General Medical and Surgical Hospitals","slug":"general-medical-and-surgical-hospitals"},{"code":"621999","title":"All Other Miscellaneous Ambulatory Health Care Services","slug":"all-other-miscellaneous-ambulatory-health-care-services"},{"code":"621498","title":"All Other Outpatient Care Centers","slug":"all-other-outpatient-care-centers"}],"jobPosting":{"@context":"https://schema.org","@type":"JobPosting","title":"Utilization Review Specialist","description":"If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.\n\nCorporate, Admin, Mgt. Full Time Office/Clerical Birmingham, AL, US\n\n2 days ago Requisition ID: 5974\n\nAbout Company\nWe’re officially a Great Place To Work®! We’ve always believed that supporting our team is just as important as supporting our patients. Now, we’re proud to share that we’ve earned Great Place To Work® Certification - based entirely on feedback from our own employees.\n\nThis certification reflects the culture we’ve worked hard to build - one rooted in trust, inclusion, and purpose-driven leadership.\n\nAt Bradford Health Services, we are committed to providing exceptional care to our patients while fostering a supportive and rewarding workplace for our employees. We believe that taking care of our team allows them to take better care of others, which is why we offer a comprehensive benefits package designed to support their well-being.\n\nOur benefits include:\n\nMedical Coverage\nThree new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits.\n\nExpanded Coverage\nOptions for domestic partners and a wider network of in-network providers.\n\nMental Health Support\nImproved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching.\n\nVoluntary Coverages\nPet insurance, home and auto insurance, family legal services, and more.\n\nStudent Loan Repayment\nAvailable for nurses and therapists.\n\nRetirement Benefits\n401(k) plan through Voya to help employees plan for the future.\n\nGenerous PTO\nA robust paid time off policy to support work-life balance.\n\nVoluntary Benefits for Part-Time Employees\nDental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week.\n\nAbout the Role\nThe Utilization Review Specialist plays a critical role in ensuring that healthcare services provided to patients are medically necessary, efficient, and compliant with regulatory standards. This position involves thorough evaluation of patient records, treatment plans, and clinical data to determine the appropriateness of care and resource utilization. The specialist collaborates closely with healthcare providers, insurance companies, and case managers to facilitate timely approvals and optimize patient outcomes. By applying clinical knowledge and regulatory guidelines, the role helps control healthcare costs while maintaining high-quality patient care. Ultimately, the Utilization Review Specialist contributes to the integrity and sustainability of healthcare delivery systems across the United States.\n\nMinimum Qualifications\n\nBachelor’s degree in a healthcare or related field.\n\nAt least 2 years of experience in utilization review, case management, or clinical healthcare roles.\n\nStrong knowledge of medical terminology, clinical procedures, and healthcare regulations.\n\nFamiliarity with insurance authorization processes and healthcare reimbursement models.\n\nExcellent analytical, communication, and organizational skills.\n\nPreferred Qualifications\n\nExperience with electronic health records (EHR) systems and utilization management software.\n\nCertification in Utilization Review (e.g., Certified Professional in Utilization Review or Certified Case Manager).\n\nPrior experience working with managed care organizations or insurance companies.\n\nAdvanced knowledge of Medicare, Medicaid, and other payer-specific guidelines.\n\nResponsibilities\n\nReview and analyze medical records, treatment plans, and clinical documentation to assess the necessity and appropriateness of healthcare services.\n\nCoordinate with healthcare providers, insurance representatives, and case managers to obtain additional information and clarify treatment details.\n\nMake informed decisions regarding authorization, continuation, modification, or denial of services based on clinical guidelines and regulatory requirements.\n\nMaintain accurate and detailed records of utilization review activities, decisions, and communications in compliance with organizational policies and legal standards.\n\nStay current with evolving healthcare regulations, payer policies, and clinical best practices to ensure consistent and compliant review processes.\n\nSkills\nThe Utilization Review Specialist applies clinical expertise and analytical skills daily to evaluate patient care plans against established medical criteria and payer policies. Effective communication skills are essential for collaborating with multidisciplinary teams, including physicians, nurses, and insurance representatives, to gather necessary information and explain review decisions. Organizational skills enable the specialist to manage multiple cases simultaneously while maintaining detailed documentation and meeting deadlines. Proficiency with healthcare IT systems supports efficient data retrieval and documentation of utilization review activities. Continuous learning and adaptability are important to stay updated on regulatory changes and evolving clinical standards, ensuring compliance and optimal patient care.\n\n#J-18808-Ljbffr","datePosted":"2026-10-26T04:05:30.853Z","dateModified":"2026-10-26T04:05:30.853Z","hiringOrganization":{"@type":"Organization","name":"Automatic Data Processing","sameAs":"https://jobsearcher.com"},"jobLocation":{"@type":"Place","address":{"@type":"PostalAddress","addressLocality":"Lucedale","addressRegion":"MS","addressCountry":"US"}},"identifier":{"@type":"PropertyValue","name":"JobSearcher","value":"1dc08beb85b2c014aa0e23d0"},"url":"https://jobsearcher.com/jobs/1dc08beb85b2c014aa0e23d0"}}