Utilization Review Specialist

Position Summary:
The Utilization Review Specialist ensures the medical necessity, accuracy, and compliance of procedures and services performed within the ophthalmology clinic and ambulatory surgery center (ASC). This role focuses on documentation review, payer compliance, and collaboration across departments to promote efficient, compliant care delivery and accurate reimbursement.

Key Responsibilities:

• Review clinical documentation to confirm medical necessity and ensure compliance with payer and regulatory requirements.
• Identify and communicate documentation gaps or discrepancies to physicians and clinical staff.
• Collaborate with billing and coding teams to ensure alignment between clinical documentation, coding, and reimbursement requirements.
• Assist in the timely resolution of authorization issues and other payer-related delays.
• Monitor denials and trends, supporting process improvements that reduce rework and enhance reimbursement accuracy.
• Maintain current knowledge of payer guidelines, coverage policies, and ophthalmology-specific procedures.
• Participate in internal audits and quality improvement initiatives to strengthen documentation and compliance.
• Provide feedback and education to staff regarding payer documentation expectations and utilization review findings.

Qualifications:

• Associate’s or Bachelor’s degree in healthcare administration, nursing, or related field preferred.
• Minimum of two years’ experience in utilization review, medical billing, or compliance within a medical practice or ASC; ophthalmology experience preferred.
• Solid understanding of payer requirements, ICD-10/CPT coding, and medical necessity criteria.
• Strong communication, organization, and problem-solving skills.
• Proficiency in EHR systems and payer portals.

Work Environment:
This position works closely with the clinical, ASC, and billing teams. The role requires precision, confidentiality, and consistent follow-through in a fast-paced, detail-oriented environment.