Utilization Management Clinical Specialist

What to expect:

• Provides timely comprehensive utilization reviews for behavioral health services for Sheppard Pratt patients.
• Conducts medical reviews for inpatient and partial hospitalization programs maintains accurate documentation within hospital data systems and communicates effectively with internal stakeholders and external agencies.
• Coordinates with Medicare Medicaid and Commercial Health Plans to ensure compliance with CMS (Centers for Medicare & Medicaid Services) Maryland Medicaid and payer-specific requirements.
• Leads the appeals process through data-driven analysis optimized workflows and strengthened clinical documentation to support medical necessity decisions and successful appeal outcomes.

What youll get from Us:

At Sheppard Pratt you will work alongside a multi-disciplined team led by a bold vision to change lives. We offer:

• A commitment toprofessional developmentincludinga comprehensive tuition reimbursement program tosupport ongoing education and licensure and/or certification preparation

• Comprehensive medical dental and vision benefitsfor benefit eligible positions

• 403b retirement match

• Generous paid-time-offfor benefit eligible positions

• Complimentary Employee Assistance Program (EAP)

• Generous mileage reimbursement program

Pay for this position is determined ona number offactors including but not limited toyearsand levelof related experience.

What we need from You:

• Associate or Bachelorsdegree in nursingBachelors orMastersdegree inClinical CounselingHealthcare Administration or related clinical field.
• Active RN license Licensed Clinical Professional Counselor(LCPC) or Licensed Certified Social Worker-Clinical (LCSW-C).
• Minimum of 3-5 years of experience inutilizationmanagementorbehavioral health.
• Strong knowledge of payer requirements clinicalcriteriaand behavioral health diagnosis.

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Required Experience:

IC