Utilization Review Coordinator

Title: Utilization Review Coordinator

Reports to: Senior Director of Revenue Cycle Management 

Department/Location: Remote, but only considering candidates in PST.

FLSA Status: Exempt

Travel Requirement: None

Summary: 

The Utilization Review Coordinator will report directly to the Senior Director of RCM. This team member will be responsible for handling pre-certifications, authorizations, retro-authorizations, appeals, medical records requests, and chart auditing duties that coincide with accurate reporting of each client’s clinical level of care, program, and treatment days utilized. The Utilization Review Coordinator should be a subject matter expert on payor requirements and expectations. This role requires strategic planning and coordination with on-site providers and the revenue cycle department to obtain optimal utilization review outcomes.

Responsibilities: 

• Utilization Review on Behalf of the Clinics:
  • Prescreen referrals to project/anticipate authorizations. Provide recommendations regarding level of care/services and treatment planning.
  • Conduct live reviews with payors and level of care chart reviews, conceptualizing the clinical presentation and care needs and applying medical necessity guidelines and /or LOCUS to compel authorization.
  • Clinically negotiate authorization outcomes with the payor, collaborating in advance with the primary treating clinicians.
  • Coordinate Peer-to-Peer (P2P) Review preparation and assist with scheduling. Provide guidance and training to clinicians on completing P2P reviews.
  • Establish internal authorization or denial determinations for No Authorization Required (NAR) requests.
  • Establish post denial appeal response recommendations.
  • Obtain portal access to any utilization review portals for an efficient and scalable process.
• Interdepartmental Relations and Communication:
  • Coordinate with the clinical team on requests with clinically weaker presentations.
  • Coordinate all concurrent insurance reviews with clinicians and medical team.
  • Provide guidance on specific interventions or areas on which to focus to result in maximum authorized days.
  • Provide ongoing feedback and recommendations for improvement to meet payor medical necessity guidelines.
  • Attend and participate in daily huddles/weekly rounds as the payor expert to ensure appropriate authorization outcomes and provide ongoing education regarding payor requirements.
  • Communicate with relevant parties at the facility and in RCM about any issues with coverage or denials, facilitating client notifications as needed.
  • Partner with intake, utilization review, and finance for best practices in overarching company goals related to RCM.
  • Timely completion of the Denial Notification process.
•  Accurate Data Entry:
  • Document deficiencies for identification on the daily reporting
  • Timely documentation of authorization in KIPU/Avea
  • Upload authorization letters to KIPU/Avea UR module.
•  Clinical Auditing:
  • Notify the primary therapist of any missing documentation or delinquent services
  • Review medical records for quality clinical documentation and compliance with licensing, accrediting, and payor requirements
  • Running daily reports to ensure that all information needed for timely review has been entered into the EMR and communicating with the clinic team members to correct or update any missing or incorrect documentation.
•  Policy Compliance:
  • Ensuring compliance with legal, regulatory, and policy requirements.
•  Process Improvement:
  • Identifying Clinical problems and proposing innovative solutions.
•  Additional job duties as assigned.

Qualifications:

• Bachelor's degree in Social Work, Nursing, or any related field.
• Must be based in PST, with an understanding of the west coast Payer landscape (ideally CA or WA).
• Clinical or UR experience in PHP or IOP levels of care.
• 1-2 years of experience in the healthcare industry in utilization review or clinical care.
• Expert understanding of patient documentation, chart auditing, and state and federal regulations.
• Proficient in MS Office applications and ability to learn department and job-specific software systems (e.g., applicable practice management and EMR systems)
• Demonstrate organizational skills.
• Demonstrate effective verbal and written communication skills.
• Demonstrate analytical skills when problem-solving.
• Demonstrate high attention to detail and a high degree of accuracy.