Utilization Review Specialist in Los Angeles at Los Angeles Community Hospital

Date Posted: 11/29/2019

Job Snapshot

  • Employee Type:
  • Location:
    4081 East Olympic Boulevard
    Los Angeles
  • Experience:
    Not Specified
  • Date Posted:
  • Job ID:

Job Description

Utilization Review Specialist

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

The Utilization Review Specialist will provide quality assurance and 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.

Job Responsibilities/Duties

  • Under the direction of the Director of Case Management, the Utilization Review Specialist is responsible for completing medical necessity reviews.
  • Using clinical knowledge and experience, the Utilization Review Specialist reviews provider requests for medical necessity documentation / clinical review, working closely with nurses, case managers and providers to collect all information necessary to formulate a thorough medical necessity review. It is within the reviewer’s discretion to send requests for additional information and/or request clarification. In addition to the application of the non-physician reviewer guidelines, the Utilization Review Specialist formulates a 'stand alone narrative' review for each case.
  • The Utilization Review Specialist uses  his / her professional judgment to evaluate the request to ensure that appropriate services are approved, recognizes care coordination opportunities and refer those cases as needed.
  • Ensures accurate documentation of clinical information to determine and support medical necessity criteria, level of care and contract benefits.
  • Responsible for concurrent queries from attending and treating physicians for documentation specificity.
  • Utilizes allocated resources to support review determinations.
  • Identifies and makes referrals to appropriate staff / department (Medical Director, Case Manager, Compliance, Quality, Peer Review, etc.).
  • The Utilization Review Specialist will maintain current knowledge and understanding of the laws, regulations, guidelines (MCG, etc.) and policies that pertain to the organizational unit’s business and uses clinical judgment in their application.  


Minimum Education: A Bachelor’s degree in Social Work, Sociology, Criminal Justice, Psychology or another relevant field is recommended.

Minimum Experience: Previous experience in a related role is required.

Req. Certification/Licensure: None.

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:

  • Company 401K
  • Medical, dental, vision insurance
  • Paid time-off
  • Life insurance

How to Apply

To apply for this role, or search our other openings, please visit http://pmh.com/careers/ and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law: https://www1.eeoc.gov/employers/poster.cfm

Keywords: UR Specialist, Reviewer, Analyze, Audit, Modify, Quality Assurance, Quality Management, Mgmt.