Utilization Review Clinical Specialist (Full-Time/Towson)

What to expect 

• The Utilization Review Clinical Specialist provides timely, comprehensive utilization reviews for behavioral health services for Sheppard Pratt patients. Collaborating closely with the Utilization Review team and an interdisciplinary clinical team, the specialist 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. The role also involves coordinating with Medicare, Medicaid, and Commercial Health Plans to ensure compliance with CMS (Centers for Medicare & Medicaid Services), Maryland Medicaid, and payer-specific requirements. The UR Clinical Specialist 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 review, or behavioral health.  
• Strong knowledge of payer requirements, clinical criteria and behavioral health diagnosis. 
• Attend patient focused rounds in order to present concrete and expert clinical knowledge on behalf of the patient and the health plans.  
• Strong communication skills that allow for patient advocacy related to continued stay and discharge needs. 
• Essential computer skills which focus on EHR/EMR systems, data management, alongside core office skills like Microsoft Office (Excel, Word) 

WHY SHEPPARD PRATT? 

At Sheppard Pratt, we are more than just a workplace. We are a community of healthcare professionals who are dedicated to providing hope and healing to individuals facing life’s challenges. Join us and be a part of a mission that changes lives! 

#LI-SM1