PACE UTILIZATION REVIEW SPECIALIST - RN

Job Description

Job Description

Position Summary

The PACE Utilization Review Specialist – RN oversees clinical utilization management for participants enrolled in the Program for All-Inclusive Care for the Elderly. The position ensures that services are medically appropriate, cost-effective, and coordinated. This role works closely with the PACE Medical Director and interdisciplinary team to review clinical cases, manage utilization policies, and ensure regulatory compliance.

Essential Duties and Responsibilities

• Conduct concurrent and retrospective utilization reviews for acute, post-acute, and outpatient services.
• Review clinical documentation and determine appropriate levels of care based on evidence-based criteria.
• Manage inpatient and post-acute length of stay and coordinate timely discharge planning.
• Review, develop, and implement utilization management policies and workflows.
• Prepare and present clinical case summaries and recommendations to internal leadership.
• Serve as a resource for primary care providers and care managers on utilization and authorization requirements.
• Ensure appropriate service authorization for hospitalizations, referrals, and specialty services.
• Communicate with providers, payers, and internal teams regarding claim adjudication and payment status.
• Identify high-risk participants and coordinate with clinical leadership on care strategies.
• Track and report utilization metrics and trends to support program improvement.
• Oversee denial management processes and provider appeal reviews.
• Document all utilization management activities in the electronic medical record.
• Participate in interdisciplinary team meetings and care planning sessions.
• Support staff education and training on utilization management policies and standards.

Minimum Qualifications

Preferred Qualifications

Physical Demands and Work Environment

Direct Reports

PACE Medical Director