Utilization Review Coordinator

Job Overview

The Utilization Review Coordinator manages the utilization review processes efficiently, focusing on handling denials, appeals, and authorization activities. This role works closely with insurance payers, hospital teams, and clinical specialists to ensure timely approval of hospital admissions and extended stays. It involves maintaining thorough documentation, supporting process improvements, and acting as a liaison to minimize denials and improve patient care outcomes.

Key Responsibilities

• Prepare and submit initial assessments, continued stay reviews, and other payer-requested documents in compliance with regulations and payer criteria to confirm medical necessity.
• Engage with commercial payers, providing clear and precise information—leveraging input from clinical specialists—to obtain timely authorizations and reduce denials.
• Maintain updated records in case management software, including logging escalations, avoidable days, authorization details, denials, and payer communications.
• Manage Peer-to-Peer discussions for unresolved concurrent denials, ensuring alignment with hospital, corporate, and payer policies, and document outcomes thoroughly.
• Close patient cases post-discharge ensuring all documentation is complete and accessible for billing and audits; place cases on hold when awaiting authorizations or reviews.
• Track and meet performance indicators tied to the Utilization Review Service Line goals.
• Serve as a primary contact point for hospital and payer representatives to foster clear, effective communication and swift issue resolution.
• Contribute to department training programs, aiding onboarding and skill development of staff.
• Promptly respond to calls, faxes, and insurance portal inquiries delivering high-quality customer service.
• Escalate issues to management when necessary and suggest improvements to enhance operational efficiency and outcomes.
• Ensure accurate and timely updates on authorizations, denials, and delays are communicated to all relevant parties.
• Perform additional duties as assigned and maintain dependable attendance.
• Adhere strictly to all relevant institutional policies and standards.

Qualifications

• High School Diploma or GED is mandatory; Bachelor's Degree is preferred.
• Between zero and two years' experience in utilization review, hospital admissions, or registration is required.
• Preference given to candidates with one to three years of experience in office or processing center settings.

Skills and Abilities

• Solid understanding of utilization management protocols, payer expectations, and healthcare regulations.
• Familiarity with case management software and tools essential for tracking authorizations and documentation.
• Strong communication and interpersonal skills for effective collaboration with payers, clinicians, and administrative personnel.
• Analytical and problem-solving abilities to address authorization challenges and denials.
• Excellent organizational capabilities to juggle multiple tasks and meet deadlines efficiently.
• Meticulous attention to detail ensuring precise documentation and policy compliance.
• Ability to train and mentor team members, nurturing a cooperative and productive work environment.