Manage utilization review processes including submissions, authorizations, denials, and appeals. Coordinate with payers, clinical specialists, and hospital staff to secure timely authorizations, document activities in case management systems, support Peer-to-Peer discussions, maintain KPIs, assist with training, and improve processes to reduce denials and optimize patient outcomes.
Job Summary
The Utilization Review Coordinator ensures efficient and effective management of utilization review processes, including denials and appeals activities. This role collaborates with payers, hospital staff, and clinical specialists to secure timely authorizations for hospital admissions and extended stays. The Utilization Review Coordinator monitors and documents all authorization activities, assists with process improvement initiatives, and serves as a key liaison to reduce denials and optimize patient outcomes.
Essential Functions
The Utilization Review Coordinator ensures efficient and effective management of utilization review processes, including denials and appeals activities. This role collaborates with payers, hospital staff, and clinical specialists to secure timely authorizations for hospital admissions and extended stays. The Utilization Review Coordinator monitors and documents all authorization activities, assists with process improvement initiatives, and serves as a key liaison to reduce denials and optimize patient outcomes.
Essential Functions
- Submits initial assessments, continued stay reviews, and payer-requested documentation, ensuring compliance with policies, regulations, and payer requirements to establish medical necessity.
- Communicates with commercial payers to provide concise and accurate information to secure timely authorizations and reduce potential denials, utilizing input from the Utilization Review Clinical Specialist.
- Monitors and updates case management software with documentation of escalations, avoidable days, authorization numbers, denials, and payer interactions to ensure accurate records.
- Coordinates Peer-to-Peer discussions for unresolved concurrent denials, ensuring the process aligns with hospital, corporate, and payer requirements. Documents outcomes in case management systems.
- Reviews and closes out cases after patient discharge, ensuring all required documentation is complete and understandable for billing and future audits. Places cases on hold as necessary to resolve pending authorizations or reviews.
- Maintains performance metrics aligned with Key Performance Indicators (KPIs) for the Utilization Review Service Line.
- Serves as a key contact for facility and payer representatives, fostering effective communication and collaboration to resolve issues promptly.
- Participates in training initiatives within the department, supporting onboarding and skill development for team members.
- Responds promptly to phone calls, faxes, and insurance portal requests, providing high standards of customer service and satisfaction.
- Escalates issues to the manager as appropriate and provides recommendations for improving operational efficiency and outcomes.
- Ensures accurate and timely communication of hospital stay authorizations, denials, and delays to all relevant stakeholders.
- Performs other duties as assigned.
- Maintains regular and reliable attendance.
- Complies with all policies and standards.
- H.S. Diploma or GED required
- Bachelor's Degree preferred
- 0-2 years of work experience in utilization review, hospital admissions or registration required
- 1-3 years of work experience in an office, processing center, or similar environment preferred
- Strong knowledge of utilization management principles, payer requirements, and healthcare regulations.
- Proficiency in case management systems and technology resources for authorization tracking and documentation.
- Excellent communication and interpersonal skills to interact effectively with payers, clinicians, and administrative staff.
- Critical thinking and problem-solving skills to analyze and resolve authorization and denial issues.
- Strong organizational skills to manage multiple priorities and meet deadlines.
- Attention to detail for accurate documentation and process adherence.
- Ability to train and support team members, fostering a collaborative and productive environment.
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Manage utilization review processes including initial and continued stay reviews, payer communications, authorization tracking, denial/appeal coordination, documentation in case management systems, KPI monitoring, peer-to-peer coordination, and training/support for team members to optimize patient authorization and reduce denials.
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