Utilization Management & Case Review Specialist

Job Category :
Provider Management

Requisition Number : UTILI
004408

• Posted :
  October 13, 2026
• Full-Time

Showing 1 location

Position Summary

The Utilization Management & Case Review Specialist is responsible for conducting utilization reviews, internal case record reviews, and quality assessments to support compliance, service quality, and positive outcomes. This position analyzes service utilization patterns, reviews documentation for accuracy and compliance, identifies trends and risk areas, and collaborates with internal teams and providers to promote continuous quality improvement.

The specialist serves as a key contributor in monitoring service effectiveness, ensuring contractual and regulatory compliance with case management paperwork, and supports improvement initiatives through data-informed recommendations and case review findings.

Responsibilities

Support/Service Delivery

• Conduct utilization reviews to assess the appropriateness, necessity, frequency, and duration of services depending on service package identified.
• Monitor service utilization trends and identify potential over utilization, under utilization, or service gaps.
• Evaluate cases to ensure services align with contractual requirements, organizational policies, and established guidelines.
• Identify trends requiring further investigation or intervention.
• Assists in the implementation of the Utilization Management Plan.
• Assist with policy and procedure development related to utilization management and case review processes.
• Assesses adherence to established service standards, policies and procedures.
• Apply standardized review tools and scoring methodologies to ensure consistency in evaluations.
• Participate in case review calibration activities to maintain inter-rater reliability.
• Identify findings, deficiencies, trends, and areas of risk through case review and utilization monitoring activities.
• Develop review summaries and corrective action recommendations.
• Monitor follow-up activities related to quality improvement initiatives and corrective action plans.
• Support preparation for external audits, accreditation reviews, and monitoring activities.
• Assist in evaluating provider performance against established quality and performance indicators.
• Collaborate with Data Outcome team to communicate findings and improvement opportunities.
• Participate in provider education and performance improvement initiatives when needed.

Documentation

• Track authorization and utilization metrics and prepare reports for leadership review.
• Perform internal case record reviews and documentation audits.
• Evaluate case management documentation for completeness, accuracy, timeliness, and compliance with regulatory and contractual requirements.
• Maintain accurate records of review findings and completed quality assurance activities.

Communication

• Communicates with internal teams and programs to streamline the utilization review process.
• Assists with communication and scheduling.

Supervision

• Receives supervision from and actively communicate with supervisor on an ongoing basis throughout the week by phone, email, written message and when possible, in person regarding program matters.

Core Competencies

Core competencies are the essential skills, knowledge, and behaviors that drive success, and they are important because they align individual performance with job duties and goals. Employees will be evaluated on these competencies through regular feedback in supervision and performance reviews to ensure they contribute effectively to professional and organizational growth.

• Collaboration – Recognizes the purpose and goals of the team and makes valued contributions in order to assist own team or project to achieve goals and/or objectives.
• Communication – Listens carefully…