Utilization Review Specialist

Your job is more than a job

General Duties

• Supports LCMC Health's mission of delivering exceptional patient care by ensuring the appropriate utilization of healthcare services through timely and accurate medical necessity reviews.
• Serves as a collaborative liaison between physicians, hospital departments, physician advisors, and third-party payers to facilitate appropriate patient status determinations and authorization processes.
• Performs pre-certification, concurrent, discharge, retrospective, and appeal reviews, including peer reviews and eligibility verification when appropriate.
• Applies standardized clinical criteria and regulatory guidelines to determine the appropriate level of care and patient classification, including inpatient, observation, and outpatient status.
• Maintains compliance with Medicare, Medicaid, and other payer requirements while supporting accurate reimbursement and regulatory standards.
• Partners with physicians, care management, revenue cycle, and billing teams to promote timely communication, reduce reimbursement delays, and support a seamless patient experience.
• Identifies potential barriers to payment eligibility or medical necessity and works collaboratively with interdisciplinary teams to resolve issues and recommend appropriate corrective actions.
• Maintains accurate and timely documentation of utilization review activities in accordance with organizational policies, accreditation standards, and regulatory requirements.
• Demonstrates a commitment to quality, service excellence, accountability, and continuous improvement while fostering positive working relationships across the organization.
• Protects patient confidentiality and complies with all applicable HIPAA, organizational, and regulatory requirements.

Experience Qualifications

2 years Utilization review/clinical

Education Qualifications

Required: Bachelor's Degree

WORK SHIFT:

Days (United States of America)

LCMC Health is a community. 

Our people make health happen. While our NOLA roots run deep, our branches are the vessels that carry our mission of bringing the best possible care to every person and parish in Louisiana and beyond and put a little more heart and soul into healthcare along the way. Celebrating authenticity, originality, equity, inclusion and a little “come on in” attitude is the foundation of LCMC Health’s culture of everyday extraordinary

Your extras

• Deliver healthcare with heart. 
• Give people a reason to smile. 
• Put a little love in your work. 
• Be honest and real, but with compassion.  
• Bring some lagniappe into everything you do. 
• Forget one-size-fits-all, think one-of-a-kind care. 
• See opportunities, not problems – it’s all about perspective. 
• Cheerlead ideas, differences, and each other. 
• Love what makes you, you - because we do

You are welcome here. 

LCMC Health is an equal opportunity employer. All qualified applicants receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability status, protected veteran status, or any other characteristic protected by law.

The above job summary is intended to describe the general nature and level of the work being performed by people assigned to this work. This is not an exhaustive list of all duties and responsibilities.  LCMC Health reserves the right to amend and change responsibilities to meet organizational needs as necessary.

 

Simple things make the difference. 

1.    To get started, take your time to fully and accurately complete the application for employment. Incomplete applications get bogged down and are often eliminated due to missing information. 

2.    To ensure quality care and service, we may use information on your application to verify your previous employment and background.  

3.    To keep our career applications up-to-date, applications are inactive after 6 months and, therefore, require a new application for employment to be completed. 

4.    To expedite the hiring process, proof of citizenship or immigration status will be required to verify your lawful right to work in the United States.