Utilization Review Specialist

Follow each patient account during inpatient stays and discharge, documenting authorization status in the electronic system and escalating disputes to the Director of Revenue. Initiate pre-certification via telephone or provider portal, review medical records to verify appropriate levels of care, and provide clinical data to insurance companies. Obtain and follow authorization for Case Management Services while tracking disputed claims by payor. Adhere to federal, state, payer, and local regulations, including CMS Conditions of Participation and agency policies. This hybrid role supports New Horizons' mission to improve community health across Indian River, Martin, Okeechobee, and St. Lucie counties.