Utilization Review Coordinator

JOB SUMMARY

 We are seeking a skilled Utilization Review Coordinator (URC) to oversee patient insurance certification, compliance with governmental regulations related to hospital stays, and the prevention of denials. Embedded within our utilization review management platform are clinical criteria guidelines, streamlining the review and documentation process. The Utilization/Risk Management department conducts perspective, concurrent, and retrospective reviews for authorization of Levels of Care (LOCs) and services, engaging with Program Managers, reviewing medical necessity records, and liaising with individuals and their families when necessary. Additionally, the department handles billing and payroll functions.

PRIMARY RESPONSIBILITIES  

• Evaluate patient records to assess severity of illness and intensity of service.
• Apply medical necessity screening criteria and clinical knowledge to ensure appropriateness of admissions and length of stays.
• Conduct initial admission, continuing stay, and 23-hour observation reviews for all patients.
• Manage case reviews in the electronic utilization review system.
• Collaborate with payor sources to communicate clinical information and secure hospital reimbursement.
• Consult with physicians and nursing staff.
• Participate in interdisciplinary care rounds for effective communication with the care team.
• Use escalation pathways to resolve identified issues.
• Document all activities and interactions in the electronic utilization review record.
• Enhance customer satisfaction among patients, families, physicians, internal and external partners, payors, and vendors.
• Submit Initial and Concurrent Authorizations to insurance companies.
• Verify client insurance coverage for authorization submission.
• Coordinate with insurance companies to resolve billing or authorization issues.
• Communicate Billing and Payroll questions from Program Managers and ensure accurate documentation before billing claims.
• Review Service Verification Forms and Time sheets to ensure precise payroll processing.
• Participate in state and local audits.
• Adhere to policies, procedures, regulations, and standards governing the agency.
• Maintain strict confidentiality according to Federal and State guidelines.
• Uphold the Professional Code of Ethics.
• Other duties as assigned.

QUALIFICATIONS

Required:  

• Bachelor’s degree in nursing, physical therapy, medical technician, HIMS, or a related medical field.
• Managed Care or Health Plan experience.
• Detail-oriented.
• Effective oral and written communication skills.
• Moderate computer proficiency – Microsoft Office Suite.
• Team-oriented approach.
• Independent functioning and autonomy.

Strongly preferred qualifications:

• Previous experience in utilization review/management.
• Experience with InterQual and/or Milliman Care Guidelines.