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Role Description

The Utilization Review Coordinator will report directly to the Senior Director of RCM. This team member will be responsible for handling:

• Pre-certifications
• Authorizations
• Retro-authorizations
• Appeals
• Medical records requests
• Chart auditing duties

The Utilization Review Coordinator should be a subject matter expert on payor requirements and expectations. This role requires strategic planning and coordination with on-site providers and the revenue cycle department to obtain optimal utilization review outcomes.

Responsibilities

• Utilization Review on Behalf of the Clinics:
  • Prescreen referrals to project/anticipate authorizations.
  • Provide recommendations regarding level of care/services and treatment planning.
  • Conduct live reviews with payors and level of care chart reviews.
  • Clinically negotiate authorization outcomes with the payor.
  • Coordinate Peer-to-Peer (P2P) Review preparation and assist with scheduling.
  • Establish internal authorization or denial determinations for No Authorization Required (NAR) requests.
  • Establish post denial appeal response recommendations.
  • Obtain portal access to any utilization review portals for an efficient and scalable process.
• Interdepartmental Relations and Communication:
  • Coordinate with the clinical team on requests with clinically weaker presentations.
  • Coordinate all concurrent insurance reviews with clinicians and medical team.
  • Provide ongoing feedback and recommendations for improvement.
  • Attend and participate in daily huddles/weekly rounds as the payor expert.
  • Communicate with relevant parties about any issues with coverage or denials.
  • Partner with intake, utilization review, and finance for best practices.
  • Timely completion of the Denial Notification process.
• Accurate Data Entry:
  • Document deficiencies for identification on the daily reporting.
  • Timely documentation of authorization in KIPU/Avea.
  • Upload authorization letters to KIPU/Avea UR module.
• Clinical Auditing:
  • Notify the primary therapist of any missing documentation or delinquent services.
  • Review medical records for quality clinical documentation and compliance.
  • Run daily reports to ensure that all information needed for timely review has been entered into the EMR.
• Policy Compliance:
  • Ensuring compliance with legal, regulatory, and policy requirements.
• Process Improvement:
  • Identifying clinical problems and proposing innovative solutions.
• Additional job duties as assigned.

Qualifications

• Bachelor's degree in Social Work, Nursing, or any related field.
• Clinical or UR experience in PHP or IOP levels of care.
• 1-2 years of experience in the healthcare industry in utilization review or clinical care.
• Expert understanding of patient documentation, chart auditing, and state and federal regulations.
• Proficient in MS Office applications and ability to learn department and job-specific software systems.
• Demonstrate organizational skills.
• Demonstrate effective verbal and written communication skills.
• Demonstrate analytical skills when problem-solving.
• Demonstrate high attention to detail and a high degree of accuracy.

Benefits

• Health & Wellness:
  • Medical, dental, vision, HealthJoy unlimited therapy, UHC wellness program, HSA/FSA options, and pet insurance.
• Time Off:
  • Responsible PTO covering vacation, sick leave, and select federal holidays.
• 401(k):
  • With company match.
• Professional Development:
  • $1,500 tuition reimbursement for ongoing education or CEUs, and opportunities for cross-licensure when applicable.