Utilization Review Coordinator

UTILIZATION REVIEW COORDINATOR

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.