Bradford Health Services

General

• Complete admission, precertification, concurrent, continued-stay, step-down, and retrospective reviews according to payer requirements and departmental workflows
• Obtain, document, and monitor authorizations across the continuum of care
• Review medical records and collaborate with treatment teams to obtain complete clinical information supporting medical necessity and requested levels of care
• Present clinical information clearly and persuasively to payer representatives using medical-necessity criteria and payer guidelines
• Maintain authorization records in electronic medical records, payer portals, tracking systems, and other applications
• Monitor caseloads and authorization deadlines daily; complete follow-up and escalate unresolved barriers
• Identify clinical documentation gaps or inconsistencies and communicate needs to clinicians, providers, or leaders
• Coordinate with clinical and case-management teams on transitions, discharge planning, and level-of-care changes
• Escalate adverse determinations requiring peer-to-peer review, reconsideration, appeal, or leadership intervention
• Prepare case summaries and supporting documentation for peer reviews, appeals, and payer escalations
• Review payer correspondence and adverse determinations, communicate outcomes, and complete follow-up
• Participate in denial review, root-cause analysis, quality audits, training, and performance-improvement initiatives
• Follow utilization review policies, workflows, escalation pathways, and documentation requirements across assigned facilities and states
• Maintain knowledge of payer policies, authorization requirements, medical-necessity criteria, regulatory standards, and service-line requirements
• Collaborate with Utilization Review leadership, admissions, clinical teams, facility leadership, Patient Financial Services, Billing, Compliance, and Revenue Cycle partners
• Protect patient privacy and ensure compliance with HIPAA, 42 CFR Part 2, payer requirements, accreditation standards, and organizational policies
• Perform other duties as assigned in support of Utilization Review and Revenue Cycle objectives

Utilization Review Specialist

• Complete admission, precertification, concurrent, continued-stay, step-down, and retrospective reviews according to payer requirements and departmental workflows
• Obtain, document, and monitor authorizations across the continuum of care
• Review medical records and collaborate with treatment teams to obtain timely clinical information supporting medical necessity and level of care
• Present clinical information to payer representatives using medical-necessity criteria and payer guidelines
• Maintain accurate authorization records in electronic medical records, payer portals, tracking systems, and other applications
• Monitor caseloads and authorization deadlines; complete follow-up and escalate unresolved barriers
• Identify clinical documentation gaps or inconsistencies and communicate needs to clinicians, providers, or leaders
• Coordinate with clinical and case-management teams on transitions, discharge planning, and level-of-care changes
• Escalate adverse determinations requiring peer-to-peer review, reconsideration, appeal, or leadership intervention
• Prepare case summaries and supporting documentation for peer reviews, appeals, and payer escalations
• Review payer correspondence and adverse determinations; communicate outcomes and complete follow-up
• Participate in denial review, root-cause analysis, quality audits, training, and performance-improvement initiatives
• Follow utilization review policies, workflows, escalation pathways, and documentation requirements across assigned facilities and states
• Maintain knowledge of payer policies, authorization requirements, medical-necessity criteria, regulatory standards, and service-line requirements
• Collaborate with Utilization Review leadership, admissions, clinical teams, facility leadership, Patient Financial Services, Billing, Compliance, and Revenue Cycle partners
• Protect patient privacy and comply with HIPAA, 42 CFR Part 2, payer requirements, accreditation standards, and organizational policies
• Perform other duties supporting Utilization Review and Revenue Cycle objectives