Utilization Review Specialist

Utilization Review Specialist

Full Time

St. Louis, MO, US

Join Us to Build Healing and Hope Together!

As leaders in children’s mental health and wellness, St. Louis Children’s and KVC Health Systems Youth Mental Health Care have partnered to create one of the nation’s most innovative and transformative youth mental health and wellness campuses. The partnership includes a 77-bed acute care hospital and outpatient programs. Located on the KVC Missouri Children’s Mental Wellness Campus conveniently located in Webster Groves, Missouri, the peaceful environment and broad continuum of care allow children and families to access the appropriate level of treatment throughout their healing experience. The new campus is slated to open in late 2026. Learn more at stlouischildrenskvc.org. Join us and be a part of this journey of healing and hope for thousands of children and teens.

Job Summary

The Utilization Review department carries with it the responsibility of managing those aspects of a patient stay that relates to the initial, concurrent and discharge interface with health plans. This role will be in frequent contact with health plans providing clinical information developed from the treatment team and staff working with the patient and family. This job is one of detail and accuracy in a very fast environment. This position is a part of the treatment team and is the primary contact with the health plan. This includes coordinating with the KVC Admissions Department, physicians, nurses and therapists to ensure timely, accurate and complete assessments are performed on children and youth, and adults, and making appropriate referrals for placement and services based on the assessment.

Education:

High school diploma or general education degree (GED) from an accredited institution required.

Licensure/Certification: 

Valid driver’s license and auto insurance.

Experience:

A minimum of two years’ experience working in case management, utilization review, wellness coordination with at least one of those years of experience working with economically disadvantaged, vulnerable or at-risk youth and/or adults.  

Skills: 

Requires Intermediate skills in Microsoft Office Suite, including Word, Excel, and Outlook email.

Strong interpersonal skills, including oral and written communication.

Preferred Experience/Skills: 

Bachelor’s degree in a human services field (I.e., social work, education, sociology, psychology, counseling, applied behavioral sciences) or criminal justice preferred.

Major Duties:

• Practice conduct that displays respect for all KVC colleagues and community stakeholders regardless of age, gender identity, sexual orientation, race, religion, ethnicity, or veteran status

• Work effectively with a wide range of constituencies, including but not limited to a multi-disciplinary internal team, external stakeholders, referral sources, other care providers, and insurance companies in a diverse community
• Ensure and monitor correct data is in electronic health records with authorizations/child specific contracts (single case agreements, etc.) 
• Assisting in mapping out contractual relationships, maintaining good relationships with these contracts and external agencies 
• Gathers data and compiles information completely and accurately andenterdata into the data management systems 
• Conducts Utilization Review functions; reports to insurance companies; files appropriate forms and writes appeals for signature 
• Gathers and summarizes information for intake assessments and discharge summary reports 
• Maintains strictest confidentiality about child/youth/adult/family information 
• Assists in maintaining compliance with state, federal and The Joint Commission guidelines 
• Will assist with completion of paperwork for admissions and assist in other duties  
• Will assist with individual assignments such as audits of meaningful use data 
• Attendstaff conferences and in-service training as required or needed
• Provide reviews of documentation to enhance quality of records and ensure compliance with standards of care 
• Support special initiatives through quality assurance roles to enhance services for consumers

Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to stand, walk, talk, or hear, and taste or smell. The employee frequently is required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance; and stoop, kneel, crouch, or crawl. The employee is occasionally required to sit for intermittent amounts of time. The employee must regularly lift and/or move up to 10 pounds, frequently lift and/or move up to 25 pounds, and occasionally lift and/or move up to 75 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Benefits & More

Employee benefits and culture fall under the KVC Health Systems umbrella. KVC is a family of private, nonprofit organizations that strengthen families, prevent child abuse and neglect, and help people achieve mental health wellness. Through our broad continuum of care, we are proud to be a national leader in mental health, child welfare, and health and human services transformation.

At KVC, we offer a positive, supportive workplace where each person can do work they love. In fact, we’re so proud of our culture that we see it as our top competitive advantage in the health and human services field. Based on the voice of our employees, KVC has an incredible 83 Work Wellbeing score on Indeed, a rating so high and rare that it places KVC among the top 1% of employers nationally. KVC was also named #15 on Glassdoor’s Best-Led Companies 2025 list, a recognition achieved entirely based on anonymous employee reviews. In addition to being mission-driven, we offer employees an unparalleled level of flexibility, wellbeing, learning, inclusion, recognition, and rewards.