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Prior Authorization Utilization Review Jobs in Nevada

UHS

UR COORDINATOR

Las Vegas, NV · On-site

... authorizations required. * Demonstrates clear and consistent understanding of admission and discharge functions. * Must be thoroughly conversant with the principles of Utilization Review and Quality ...

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Prior Authorization Utilization Review information

What is a Prior Authorization Utilization Review specialist?

A Prior Authorization Utilization Review specialist is a healthcare professional responsible for evaluating medical service requests to ensure they meet specific criteria for approval before services are provided. Their main role is to review clinical information, verify medical necessity, and ensure compliance with insurance policies and guidelines. They act as a liaison between healthcare providers, insurance companies, and patients to facilitate timely and accurate authorization decisions. This process helps to manage healthcare costs and ensure patients receive appropriate care.

What are the key skills and qualifications needed to thrive as a Prior Authorization Utilization Review specialist?

To thrive as a Prior Authorization Utilization Review Specialist, you need a strong understanding of medical terminology, insurance guidelines, and clinical criteria, often supported by a degree in healthcare or nursing and relevant certification (such as RN or LPN). Familiarity with prior authorization software, electronic health record (EHR) systems, and payer portals is typically required. Attention to detail, strong communication skills, and the ability to multitask help professionals excel in this role. These competencies ensure accurate and timely processing of authorizations, reducing delays in patient care and ensuring compliance with payer requirements.

What are some common challenges faced by professionals in Prior Authorization Utilization Review roles, and how can these be managed?

Professionals in Prior Authorization Utilization Review often encounter challenges such as navigating complex insurance policies, managing high volumes of requests, and ensuring timely communication between providers and payers. Staying organized, developing a thorough understanding of payer guidelines, and maintaining clear, consistent communication are key strategies for managing these challenges. Many teams also rely on workflow management tools and regular team huddles to streamline processes and ensure all cases are handled efficiently.

What is the difference between Prior Authorization Utilization Review vs Medical Reviewer?

AspectPrior Authorization Utilization ReviewMedical Reviewer
CredentialsLicensed healthcare professionals, often with certifications in utilization reviewLicensed physicians or healthcare providers with clinical expertise
Work EnvironmentInsurance companies, healthcare organizations, or third-party review firmsHospitals, clinics, insurance companies, or consulting firms
Primary FocusAssessing the necessity of procedures or treatments before approvalEvaluating clinical records to determine medical necessity and appropriateness

While both roles involve clinical assessment, Prior Authorization Utilization Review focuses on pre-authorization decisions for treatments, whereas Medical Review involves detailed clinical evaluation of patient records to determine medical necessity. Both require healthcare credentials and are integral to healthcare quality and cost management.

What are popular job titles related to Prior Authorization Utilization Review jobs in Nevada?

For Prior Authorization Utilization Review jobs in Nevada, the most frequently searched job titles are:

What job categories do people searching Prior Authorization Utilization Review jobs in Nevada look for?

The top searched job categories for Prior Authorization Utilization Review jobs in Nevada are:

What cities in Nevada are hiring for Prior Authorization Utilization Review jobs?

Cities in Nevada with the most Prior Authorization Utilization Review job openings:

Prior Authorization Utilization Review jobs near you

Utilization Review Specialist

Las Vegas, NV • On-site

Desert Parkway Behavioral Healthcare Hospital
Health Care and Social Assistance • 51 - 200 employees
Learn more about Desert Parkway Behavioral Healthcare Hospitalexternal

Full-time

Medical, Dental, Vision, Life, Retirement, PTO

Posted 15 days ago

Job description

We are looking for a detailed-oriented Utilization Review (UR) Specialist to help us maximize patient care quality and ensure seamless insurance operations.
The UR Specialist evaluates patient medical records to ensure treatments meet clinical necessity and regulatory standards. You will serve as the primary bridge between our medical staff and insurance providers, facilitating timely care approvals and minimizing claim denials.
Other responsibilities include retrieving discharge documents on a daily basis from charts, faxing when applicable, and retrieving authorizations.
KEY RESPONSIBILITIES:
  • Evaluate outpatient charts against established clinical criteria.
  • Submit and track insurance authorization requests.
  • Draft and submit clinical appeals for denied services.
  • Communicate directly with insurance medical directors and case managers.
  • Advise physicians and clinical staff on documentation requirements.
  • Monitor utilization trends, denial rates, and approval timelines.
  • Ensure adherence to Medicare, Medicaid, and private payer guidelines.
  • Hours are Monday - Friday from 8:00am - 4:30pm

Requirements
  • Current LPN, RN or other Clinical Licensure and/or master's degree required.
  • Minimum two (2) years of clinical experience, with 1+ years in utilization review or case management required
  • Knowledge of Nevada Payors required
  • Previous experience working in behavioral healthcare strongly preferred
  • Strong Microsoft word and excel skills required
  • Maintains confidentiality of patients at all times

Benefits
Eligible for benefits 1st of the month following one month of employment.
Desert Parkway offers competitive benefits to include:
  • Health insurance
  • Vision insurance
  • Dental insurance
  • 401K Retirement Plan
  • Healthcare spending account
  • Dependent care spending account
  • PTO Plan with holiday premium pay
  • Discounted cafeteria meal plan
  • Life insurance (Supplemental Life, Term and Universal plans are also available)
  • Short- and long-term disability (with additional buy-in opportunities)

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