17 Utilization Review Specialist Interview Questions and Answers

Utilization review specialists are responsible for making sure that patients receive the care they need while also ensuring that the facilities they work for provide services within the parameters of their budget. In order to do this, utilization review specialists need to be able to effectively communicate with both patients and medical staff.

Utilization review specialists are in high demand, which means that there is a lot of competition for jobs in this field. If you’re looking for a job as a utilization review specialist, you need to be prepared to answer a variety of utilization review interview questions.

In this guide, we’ll give you a list of some of the most common utilization review interview questions, as well as sample answers to help you prepare for your interview.

Are you familiar with the Health Insurance Portability and Accountability Act (HIPAA)?

HIPAA is a federal law that protects the privacy of an individual’s medical records. Employers ask this question to make sure you understand HIPAA and how it applies to utilization review specialists. In your answer, explain what HIPAA is and why it’s important for utilization review specialists to follow its guidelines.

Example: “HIPAA is a federal law that requires healthcare providers to protect the privacy of their patients’ medical information. Utilization review specialists must be aware of HIPAA because we are often looking at patient records when conducting our reviews. We need to ensure that we’re not sharing any private information with anyone who doesn’t have authorization to view it.”

What are some of the most important qualities for a successful utilization review specialist?

This question can help the interviewer determine if you have the skills and abilities to succeed in this role. Use your answer to highlight your critical thinking, problem-solving and communication skills. You may also want to mention any specific software or technology that you are familiar with.

Example: “The most important qualities for a successful utilization review specialist include attention to detail, strong analytical skills and excellent communication skills. Utilization review specialists must be able to thoroughly examine medical records and make sure they comply with insurance company guidelines. I find that my ability to think critically helps me identify errors and inconsistencies in patient files. My communication skills allow me to work well with other members of the healthcare team.”

How would you rate your ability to work as part of a team?

Teamwork is an important skill for utilization review specialists. They often work with other healthcare professionals to ensure that patients receive the most appropriate care and are billed appropriately. Interviewers may ask this question to learn more about your interpersonal skills and how you might fit into their team. In your answer, try to show that you value teamwork and collaboration. Explain what steps you would take to help a team function well together.

Example: “I believe that working as part of a team is one of the best ways to achieve success in any endeavor. I am always willing to lend my expertise to others and collaborate on projects. I think it’s important to communicate openly with my teammates so we can understand each other’s ideas and concerns. This helps us make decisions together and find solutions to problems.”

What is your experience with using medical terminology?

This question can help the interviewer determine your level of expertise in the medical field. Use examples from previous experience to show that you have a strong understanding of medical terminology and how it applies to utilization review.

Example: “I’ve worked with many different types of medical terms throughout my career, but I find that the most important thing is to be able to communicate clearly with other professionals who may not understand the language as well. In my last position, I was working on a case where we needed to use specific medical terminology to describe the patient’s condition. I asked for clarification when necessary so that everyone involved understood what I was referring to.”

Provide an example of a time when you identified a case of fraud within a health care provider’s records.

Interviewers may ask this question to assess your ability to detect fraud and other illegal activities within a healthcare organization. Use examples from your experience that show you can use critical thinking skills to identify potential issues, such as fraud or theft, and report them to the appropriate authorities.

Example: “In my previous role, I noticed an unusually high number of claims for one particular medication. When I investigated further, I found that the physician was prescribing the drug for conditions it wasn’t approved for. This is a violation of federal law, so I reported it to the state medical board. The board conducted its own investigation and revoked the doctor’s license.”

If hired, what areas of the health care industry would you like to focus your efforts on?

This question helps employers understand your career goals and how you plan to achieve them. Use this opportunity to show the interviewer that you have a clear vision for your future in healthcare. You can also use this time to highlight any skills or experiences that will help you reach those goals.

Example: “I would love to work as a utilization review specialist at a hospital, where I could apply my knowledge of coding and billing to ensure patients receive the most appropriate care. In my last role, I helped develop new billing codes for our department, which made it easier for us to track patient information and monitor costs. This experience has given me valuable insight into the importance of proper coding and billing.”

What would you do if you noticed a discrepancy between a patient’s reported symptoms and the details in their medical records?

Interviewers may ask this question to assess your critical thinking skills and ability to notice inconsistencies. In your answer, explain how you would investigate the discrepancy and what steps you would take to ensure it didn’t happen again.

Example: “If I noticed a discrepancy between a patient’s reported symptoms and their medical records, I would first speak with them about it. If they still report the same symptoms, then I would look at the medical record more closely to see if there was any information that could help me understand why the symptoms were different than what was recorded. If not, I would contact my supervisor so we could discuss our options for resolving the issue.”

How well do you think you would adapt to the fast-paced environment of a health care facility?

The interviewer may ask this question to gauge your ability to adapt to a busy environment. This is because utilization review specialists often work in teams and need to be able to communicate effectively with their colleagues. Your answer should show that you are comfortable working in a fast-paced environment and can collaborate well with others.

Example: “I think I would adapt quite well to the fast-paced environment of a health care facility. In my previous role, I worked as part of a team where we had to complete many tasks within a short period of time. I am used to adapting to different situations quickly and communicating clearly with my teammates.”

Do you have any experience working with medical software or other technology tools?

This question can help the interviewer learn more about your experience level and how you might fit into their organization. If you have worked with medical software or other technology tools in the past, share what you learned from that experience.

Example: “I’ve had some experience working with medical software in my previous role as a utilization review specialist. I found it helpful to use this software because it helped me understand which patients were most likely to need additional care and treatment. This information was useful when determining whether a patient should be approved for certain procedures or treatments.”

When reviewing a patient’s medical records, what is the first thing you look for?

This question is an opportunity to show the interviewer that you have a strong understanding of utilization review and how it works. Use your answer to highlight your knowledge of medical terminology, billing codes and other important details about patient care.

Example: “When reviewing a patient’s records, I look for any inconsistencies or errors in coding. For example, if a doctor billed a procedure as a Level 5 when it should be billed as a Level 3, this would result in overbilling. Utilization review specialists like myself are responsible for identifying these types of mistakes so they can be corrected before the insurance company pays out claims.”

We want to improve our compliance with federal regulations. What strategies would you use to identify areas for improvement?

This question can help the interviewer determine how you would use your expertise to improve their organization’s compliance with federal regulations. Use examples from your experience to explain how you would identify areas for improvement and implement strategies to ensure regulatory compliance.

Example: “I would first assess the current state of compliance by reviewing all relevant documents, such as policies and procedures, training records and employee performance reviews. I would then compare these results to the standards set forth in the applicable regulation to determine where improvements are needed. In my last role, I used this strategy to identify several areas that could be improved to increase our compliance with HIPAA privacy standards.”

Describe your process for ensuring that your recommendations are clear and easy to understand.

The interviewer may ask you this question to assess your communication skills and ability to write clearly. Your answer should include an example of a time when you wrote clear, concise reports that were easy for others to understand.

Example: “I always start by writing my recommendations in plain language so they’re easy to read. Then I check with the client or supervisor to make sure they understand what I’m recommending. If they don’t, I’ll go back and reword it until they do. This ensures that everyone is on the same page about how we can best use our resources.”

What makes you stand out from other candidates for this position?

Employers ask this question to learn more about your qualifications and how you can contribute to their team. When answering, it’s important to highlight the skills that make you a good fit for the role. You may also want to mention any unique or interesting experiences you have had in previous positions.

Example: “I am passionate about helping others, which is why I chose to pursue a career in healthcare. In my last position as an ER nurse, I noticed many patients were being admitted unnecessarily because of improper utilization review. I developed a system where nurses could report these cases to me so we could work together to find better solutions. This resulted in fewer unnecessary admissions and saved the hospital thousands of dollars.”

Which utilization review models are you familiar with?

This question is your opportunity to show the interviewer that you have a strong understanding of utilization review models and how they can be applied in healthcare. You should list several models, explain what each one is and describe its purpose.

Example: “I am familiar with three different utilization review models—the DRG-based system, the diagnosis-related group (DRG) minus system and the diagnosis-related group (DRG) plus system. The DRG-based system is used when there are no issues with patient care or coding. It’s also used for cases where the patient has been coded correctly but the reimbursement amount is incorrect. In these instances, I use the DRG-minus system to determine if the hospital is overpaid or underpaid. If it’s determined that the hospital is underpaid, then I apply the DRG-plus system to calculate the correct payment amount.”

What do you think is the most important skill for a utilization review specialist to have?

This question can help the interviewer determine what skills you value most in your role as a utilization review specialist. When answering this question, it can be helpful to identify one or two specific skills that are important for success and explain why they’re important.

Example: “I think the most important skill for a utilization review specialist is attention to detail. This is because I believe it’s essential to thoroughly examine each patient record before making any decisions about how much of their care will be covered by insurance. Attention to detail helps me ensure that I’m looking at all relevant information when performing my reviews.”

How often do you recommend denying claims?

This question can help an interviewer understand your decision-making process and how you handle conflict. Use examples from past experiences to explain the steps you take when denying claims, including how you communicate with clients about your decisions.

Example: “I always recommend denial only after thoroughly reviewing a claim for errors or inconsistencies. I find that most of my recommendations are due to missing documentation or insufficient information in medical records. In one instance, I denied a client’s claim because they failed to provide me with their physician’s credentials. The client was upset at first but understood why I had to deny their claim.”

There is a discrepancy between a patient’s reported symptoms and what is in their medical records. What is your response?

This question is an opportunity to show your critical thinking skills and ability to make decisions. When answering this question, it can be helpful to give a specific example of how you handled the situation in the past.

Example: “When I have encountered this situation in the past, I first look at all of the patient’s records to see if there are any other symptoms that may not have been reported. If there aren’t, then I will contact the physician who treated the patient to ask them about the discrepancy. In my experience, physicians are usually happy to explain why they didn’t report certain symptoms. However, if they don’t respond or their explanation doesn’t seem sufficient, I would recommend that the claim be denied until more information could be obtained.”