Utilization review specialists provide quality assurance within the medical field. Common employers for these specialists include clinics, physical therapists’ offices and hospitals, among others. They perform quality control related to patient treatment by medical staff (such as nurses and physicians), making sure that staff provide adequately for patients’ comfort, health and safety. Utilization review specialists may interview patients and their families, and they must inform designated managers or directors immediately whenever they encounter reportable conditions, critical incidents and accidents.
At all times, utilization review specialists must follow patient privacy laws. To keep their skills up to date, they may attend workshops, conferences or training classes. Utilization review specialists may be required to coach or mentor new or more junior specialists as well.
A bachelor’s degree in social work, sociology, criminal justice, psychology or another relevant field is generally the minimal educational requirement for utilization review specialist positions. Previous experience in a related role is generally required or preferred as well; some employers may accept substantial experience in lieu of a degree. Utilization review specialists must have excellent communication and interpersonal skills, as these specialists are required to work closely with their institution's staff and patients and their families. Additionally, utilization review specialists must be proficient with basic computer programs, able to work well in a team environment and able to work well on their own with minimal supervision.
Utilization Review Specialist Tasks
Audit and analyze patient records to ensure quality patient care and appropriateness of services.
Interview or correspond with physicians to correct errors or omissions and to investigate questionable claims.
Analyze information gathered by investigation, and report findings and recommendations.
Modify patient treatment plans as indicated by patients' responses or case history.