Utilization Review Representative

Job Details: Job Location: REMEDIAL PRO

• Boca Raton, FL, Salary Range: Undisclosed, POSITION SUMMARY The Utilization Review Specialist is responsible for conducting and coordinating utilization review activities to support appropriate, medically necessary, and cost-effective patient care. This position reviews clinical documentation, monitors authorization and review requirements, coordinates with clinical staff and external stakeholders, and supports compliance with applicable policies, procedures, and payer requirements. The Specialist works collaboratively with the treatment team and other departments to promote timely reviews, accurate documentation, continuity of care, and effective utilization of services.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Conduct timely utilization reviews in accordance with applicable payer requirements, organizational policies, and established procedures. Review clinical records and supporting documentation for completeness, accuracy, and alignment with medical-necessity and authorization criteria. Prepare, submit, and track clinical documentation and authorization requests; follow up on pending reviews, requests for additional information, and payer determinations.

Coordinate with clinical staff, providers, insurers, patients, and other relevant parties to support timely reviews and continuity of care. Communicate review outcomes, authorization status, documentation needs, and applicable deadlines to appropriate members of the care team. Maintain accurate, organized, and timely records of utilization review activities, communications, authorizations, and related decisions.

Identify potential barriers, delays, documentation gaps, or utilization concerns and escalate them to the appropriate supervisor or clinical leader. Monitor review timelines and outstanding items to help ensure required reviews and follow-up activities are completed within established deadlines. Assist with compiling data, preparing reports, and identifying trends related to utilization review activity, authorization outcomes, and process performance.

Support the implementation and consistent application of utilization review policies, procedures, and process improvements. Maintain confidentiality and handle patient information in accordance with organizational requirements and applicable privacy laws and regulations. Participate in meetings, training, audits, and quality-improvement activities related to utilization review, as assigned.

Perform other related duties as assigned.

QUALIFICATIONS

Experience in utilization review, behavioral health, healthcare administration, case management, or a related field preferred. Knowledge of clinical documentation, medical-necessity review processes, authorization workflows, and payer requirements preferred. Ability to review and interpret clinical information and identify missing documentation or items requiring follow-up.

Strong written and verbal communication skills, with the ability to coordinate effectively with clinical teams and external stakeholders. Strong organizational skills and the ability to prioritize multiple cases, deadlines, and follow-up requirements. Proficiency with electronic health records, utilization review systems, and standard office software.

Ability to maintain confidentiality, exercise sound judgment, and work collaboratively in a fast-paced environment.

EDUCATION AND EXPERIENCE

High school diploma or equivalent required. Additional education in healthcare, behavioral health, nursing, social services, or a related field is preferred. Relevant utilization review or healthcare experience may be considered in place of additional education, consistent with organizational requirements. WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS This position primarily performs administrative and computer-based work and requires regular communication with internal and external stakeholders.

The employee must be able to use electronic systems, review records, and manage time-sensitive assignments. Reasonable accommodations may be made to enable qualified individuals to perform the essential functions of the position. ROLE SCOPE This is an individual-contributor position and does not include formal team-lead or supervisory responsibilities.

The Specialist is expected to manage assigned utilization review work independently, collaborate with the care team, and escalate complex issues or decisions requiring supervisory or clinical leadership review. Acknowledgment I acknowledge that I have reviewed this job description and understand the general duties and responsibilities of the position.

This document is not intended to be an exhaustive list of all duties, and responsibilities may be changed as business needs require. Qualifications: