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Role Description

BHPS provides Utilization Review services to its clients. The UM Denials Coordinator supports the Utilization Management function by reviewing denied and partially denied authorizations and preparing denial correspondence within the Utilization Management system. This role is responsible for drafting, editing, and formatting denial and partial denial letters to ensure clarity, accuracy, completeness, and appropriate readability, while maintaining compliance with regulatory requirements and client-specific service level agreements.

The position works closely with physicians and nursing staff and may require follow-up phone calls or email communication to clarify determinations, obtain additional information, or resolve discrepancies prior to letter release. The UM Denials Coordinator reports to the Clinical Services team and performs a range of moderately complex administrative and operational tasks in support of UM activities. This is a fast-paced, productivity-driven role that requires strong attention to detail, sound judgment, and the ability to manage competing priorities.

Qualifications

• LPN license required.
• Two or more years of experience in Utilization Management or medical necessity Appeals.
• Strong verbal and written communication skills.
• Demonstrated customer service skills, including effective written and verbal communication.
• Proficient in Microsoft Office applications, including Word, Excel, and Outlook, in a Windows-based environment.
• Ability to adapt quickly to changing business needs and learn new processes and systems.

Requirements

• Review denied authorization cases within the Utilization Management system to understand the clinical determination and supporting rationale prior to letter creation or finalization.
• Draft, edit, and format denial and partial denial letters based on authorization determinations, including creation of member friendly letter language, accurately copying and inserting approved clinical statements, criteria citations, and other information into correspondence templates.
• Apply working knowledge of Utilization Management processes and sound judgment to ensure all written correspondence is clear, readable, complete, and accurate.
• Ensure all letter content, data fields, and member, provider, and service details are accurately populated to prevent compliance risks or downstream operational issues.
• Communicate with physicians and nursing staff as needed to clarify determinations, obtain missing information, or resolve discrepancies prior to letter release.
• Prioritize and triage denied authorization cases in alignment with client-specific requirements and regulatory turnaround times.
• Respond to and resolve member and provider inquiries related to denied authorizations and denial correspondence.
• Responsible for pulling and analyzing reporting around denial processes and presenting analysis to leadership.
• Perform other related duties as assigned.

Benefits

• Previous experience reviewing or writing UM denial letter language.
• Proficient/Experienced with CPT4 and ICD-10 codes.
• Working knowledge of URAC and NCQA documentation standards.