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 you’ll 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 to professional development, including a comprehensive tuition reimbursement program to support ongoing education and licensure and/or certification preparation
• Comprehensive medical, dental and vision benefits for benefit eligible positions
• 403b retirement match
• Generous paid-time-off for benefit eligible positions
• Complimentary Employee Assistance Program (EAP)
• Generous mileage reimbursement program

Pay for this position is determined on a number of factors, including but not limited to, years and level of related experience.

What we need from You:

• Associate or Bachelor’s degree in nursing, Bachelor’s or Master’s degree in Clinical Counseling, Healthcare 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 in utilization management, or behavioral health.
• Strong knowledge of payer requirements, clinical criteria and behavioral health diagnosis.