Utilization Management Specialist

Job Summary

A company is looking for a Utilization Management Specialist to support product launch and optimize healthcare resource use.

Key Responsibilities

• Review and refine AI-generated determinations of medical necessity and patient status according to established guidelines
• Collaborate with teams to define rules for care transitions and utilization
• Support the design of clinical workflows for real-time decision-making in hospital settings

Required Qualifications

• Medical degree (RN or similar clinical background)
• Direct experience in hospital utilization review or case management
• Strong understanding of CMS guidelines and utilization review standards
• Familiarity with tools like InterQual or MCG for patient tracking
• Ability to adapt and contribute across multiple functions