Utilization Management & Case Review Specialist

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 overutilization, underutilization, 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. 

1. 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. 
2. Communication – Listens carefully to understand others and prevent miscommunication. Communicates clearly and respectfully, adjusting the message to suit the audience. 
3. Computer Literacy – Uses technology and systems to achieve program goals and adapts to changes in technology needs. Ensures data is accurate, up to date, and complete. Follows security standards and technology policies at all times. 
4. Complexity and Judgement – Gathers and analyzes data to identify trends and make informed decisions. Uses available information to solve problems and find effective solutions. Continuously seeks improvement, adapts to change, and takes responsibility for outcomes. 
5. Creativity and Foresight – Develops new ideas to improve work processes and tasks. Uses proven solutions but explores new methods when needed. Contributes creatively in group settings and understands how their role affects the larger organization. 
6. Serves All – Respects and accepts the values, customs, and differences of others. Seeks to learn and understand individuals and groups different than oneself through ongoing learning. 
7. Finance – Stays aware of costs and manages expenses responsibly, such as mileage, supplies, etc. and submits timely, to support the program or department's budget. 
8. Leadership – Leads by serving others first, showing care for families and communities. Listens actively, shares knowledge, and builds strong, positive relationships with clients, coworkers, and leaders. Acts with integrity and takes responsibility for their actions. 
9. Support Focus – Applies organizational values and principles in daily work. Delivers accurate, complete, and reliable service to internal departments. Understands and meets internal customer needs through training, follow-up, and effective problem-solving. 
10. Professionalism – Shows credibility through strong work ethic, accountability, professionalism, and ethical conduct. Is reliable, follows policies, and consistently comes prepared. Maintains appropriate boundaries with children, clients, and families in all interactions. 
11. Risk Management and Safety – Uses knowledge to identify, assess, and manage risks that could harm the program or department. Stays informed about safety requirements and completes necessary training to ensure a safe environment for everyone involved. 
12. Planning, Organizing, and Time Management – Turns objectives into clear, efficient plans and meets deadlines, even when facing obstacles. Organizes, re-prioritizes, and adapts to stay on track and achieve goals. 

Qualifications 

Education/Credentials/Licensure: 

• Bachelor’s Degree in Healthcare Administration, Social Work, Human Services, Business Administration, Public Administration, Information Systems, or related field. 
• Requires a valid Driver’s License and auto insurance.  

Experience:  

• Three (3) years of professional experience in quality assurance, utilization management, compliance, auditing, case review, provider performance, healthcare, behavioral health, child welfare, managed care, or a related field.    
• One (1) year of experience with the Texas child welfare system including DFPS, Child Placing Agency, General Residential Operation/Residential Treatment Center, or Single Source Continuum Contractor preferred. 

Clearances:  

• DPS 
• DFPS 
• FBI 
• CBCU Eligibility Determination 
• Child abuse clearances 

Working Conditions 

Physical Demands 

1. This position requires operating a keypad device and electronic/office equipment 100% of the day. Travel is required approximately five (5) times per year but can vary and does not work in weather conditions other than travel. Fingers, thumbs, hands, wrists, elbows, legs and feet are all routinely used throughout the day. The lower and upper torso is used 50% of the day. Employee must meet minimum requirements for hearing, speech, and vision. Sitting happens 100% of the day. Reaching above the shoulder as well as bending and twisting are performed 10% of the day. The maximum lift is 25 pounds, one (1) time per day. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.   

Mental Demands 

1. Frequently makes quick decisions and occasionally has distractions that interfere.  
2. Continually has need to concentrate, handle a diversity of problems, and perform multiple tasks.   

Environmental Factors 

1. Environmental factors require this position offices and various Pressley Ridge locations/ program inclusive of schools and residential settings.      
2. Travel, local and overnight, to various programs/ regions is expected on an as-needed basis to fulfill the duties/ responsibilities of the position. 

Working Hours 

1. Traditional office hours with flexibility to meet department and employee/ program needs.