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What Is an Utilization Review Specialist and How to Become One


What Is a Utilization Review Specialist?

Utilization review specialists assess plans for patient care and determine what treatment is appropriate and most cost-effective. They investigate disputed medical claims, coordinate utilization training for the medical staff, analyze electronic medical records, and inform medical staff whether a medical claim is denied, approved, under review, or under appeal. In many cases, the utilization review specialist serves as an advocate for quality patient care, cost reduction, and hospital quality standards.

How to Become a Utilization Review Specialist

Many employers prefer utilization review specialists who have an associate or a bachelor's degree in a medical or health-related field, though some may consider candidates without a degree who have extensive experience in medical billing and health care quality assurance roles. Health care organizations often seek medical professionals, such as nurses, EMTs, and medical technicians, to transition into utilization review specialist positions. You must be proficient in medical coding and terminology and know how to interpret medical records and industry journals. Additional qualifications include excellent communication and organizational skills, attention to detail, and the ability to work independently.