Utilization Review Specialist - Appeals

UTILIZATION REVIEW APPEALS SPECIALIST

RN or Master's Licensed Behavioral Health Clinici an preferred

The Georgia Business Center is a centralized office for multiple Universal Health Services facilities. Due to our growth, we are seeking a dedicated and compassionate clinician to join our healthcare team as a Market Appeals Specialist in Utilization Review for the Atlanta Market Hospitals.

The Appeals Specialist supports utilization management (UM) shared services within the behavioral health division for our three acute care behavioral health facilities in the greater Atlanta area. The role oversees and coordinates all standard appeals within these hospitals with the goal of help ing enhance revenue through the standardization of our appeals operations. By the end of the third quarter, all three facilities will be utilizing Cerna as their EMR of record.

Responsibilities for this career oriented position include:

• Timely completion of standard appeal letters.
• Utilizing medical records to accurately present the clinical status of patients to support the requested level of care.
• Appropriate and timely follow-up with payers for facility reimbursement.
• Tracking and monitoring all standard appeal inventory.
• Attending facility Utilization Management meetings as needed.
• Supporting ongoing partnerships with facilities to optimize payment reimbursement through appeals.

Qualifications:

• RN or master's level clinician preferred.
• 3-5 years of experience in utilization management operations, including experience with appeal letters and payer engagement.
• Knowledge of payer requirements for reimbursement across all levels of care.
• Understanding of medical necessity criteria application for all levels of care.

Licensure/Certification:

• RN or Master's prepared Clinician licensure in the state of Georgia is preferred, but not required.

Specialized Skills/Knowledge:

• Proficiency in Excel, Microsoft Office/Teams, Word, and database inventory management.
• Strong written and oral communication skills to represent patient progress and treatment in behavioral health.
• Ability to apply clinical acumen in behavioral health to written correspondence.
• Capability to work independently in a multifaceted, fast-paced environment with dependencies on local facility teams.
• Knowledge of behavioral health business office operations.

Essential Job Duties and Responsibilities:

• Participate in local facility UM team meetings to support the standard appeal process (15%).
• Complete all standard appeals timely and manage appeal inventory (50%).
• Provide feedback to providers and UM team on opportunities impacting facility recoveries (e.g., documentation) (10%).
• Act as a liaison with local facilities and payers to ensure timely appeal processing (20%).
• Perform other duties as assigned (5%).

About Universal Health Services

One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 500 corporation, annual revenues were $15.8 billion in 2024. UHS was again recognized as one of the World’s Most Admired Companies by Fortune; listed in Forbes ranking of America’s Largest Public Companies. Headquartered in King of Prussia, PA, UHS has approximately 99,000 employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom.

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