**Job Summary**

The Clinical Utilization Review Specialist is responsible for evaluating the necessity, appropriateness, and efficiency of hospital services to ensure compliance with utilization management policies. This role conducts admission and continued stay reviews, supports denials and appeals activities, and collaborates with healthcare providers to facilitate efficient patient care. The Clinical Utilization Review Specialist monitors adherence to hospital utilization review plans and works to optimize hospital resource utilization, reduce readmissions, and maintain compliance with payer requirements.

**Essential Functions**

+ Performs admission and continued stay reviews using evidence-based criteria, clinical expertise, and regulatory guidelines to ensure appropriate utilization of hospital services.
+ Collaborates with physicians and clinical teams to obtain necessary documentation for medical necessity, discharge planning, and payer requirement...