Project Utilization Review Specialist - Corporate

Project Utilization Review Specialist - Corporate | Summit Healthcare Mgmt | Nashville, Tennessee

About the Job:

The Project Utilization Specialist provides critical leadership in revenue cycle management by providing strategic interim oversight and director level support to Summit BHC facilities. This position ensures the optimization of clinical documentation and utilization review processes, directly impacting successful authorization outcomes, minimizing denials, and enhancing reimbursement efficiency. By implementing process improvements, and collaborating closely with facility leadership, this role is essential in driving financial success and mitigating risks associated with utilization management.

Roles and Responsibilities:

• Provide interim leadership and support by filling in during director vacancies, ensuring continuity in utilization review processes and maintaining successful revenue outcomes.

• Provide on-site and virtual assessment and strategic analysis of utilization review processes across multiple Summit BHC facilities, ensuring compliance with corporate objectives and revenue cycle best practices.

• Conduct comprehensive audits of clinical and financial documentation to identify root causes of denials, trends in payer behavior, and opportunities for process enhancements. 

• Develop and implement strategies to improve authorization efficiency, reduce denial rates, and maximize reimbursement through proactive denial prevention and appeals management.

• Collaborate with corporate and divisional leaders to align utilization review efforts with revenue cycle objectives, ensuring optimized financial operations and reduced unfunded days.

• Provide execute-level consultation on payer requirements, level-of-care guidelines, and appeals processes, equipping facility teams with the necessary tools to navigate complex payer expectations.

• Deliver targeted training and mentorship to facility staff on effective documentation, utilization review strategies, and appeal letter writing to strengthen compliance and financial outcomes.

• Ensure proper utilization of revenue cycle management tools such as Medik and Salesforce, promoting standardization and efficiency across facilities.

• Evaluate and enhance collaboration between Admissions, Utilization Review, Clinical staff, Business Office, and Marketing teams to improve overall revenue cycle performance.

• Maintain up-to-date knowledge of regulatory requirements, including Medicare, Medicaid, and EMTALA standards, ensuring compliance and risk mitigation.

• Extensive overnight travel required, up to 100% of the time.  Employee will need to be flexible to accommodate changes in business travel requirements, often with minimal advance notice.

Education/Experience/Skill Requirements:

• Bachelor’s degree in Nursing or other clinical degree required.

• At least three years’ experience in Utilization Management/Review or Case Management required.

• RN, LPC, LCSW, LADAC/LDAC or LMFT preferred.

• Good knowledge of payor clincal guidelines; experience writing appeal letters.

• Significant behavioral healthcare experience in a variety of settings.

• Knowledge of insurance billing requirements.

Why Summit Healthcare Mgmt?Summit Healthcare Mgmt offers a comprehensive benefit plan and a competitive salary commensurate with experience and qualifications. Qualified candidates should apply by submitting a resume. Summit Healthcare Mgmt is an EOE.

Veterans and military spouses are highly encouraged to apply. Summit BHC is dedicated to serving Veterans with specialized programming at our treatment centers across the country. We recognize and value the unique strengths of the military community in supporting our mission to serve those who have served.