Community Health Systems

Operates acute care hospitals nationwide

Utilization Review Coordinator

Clinical Support & Patient AdministrationConfirmed live in the last 24 hours

Full-timeUnited StatesNo salary listedIn-person

About the Job

Requirements

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

Responsibilities

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

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

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.

Qualifications

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

Knowledge, Skills and Abilities

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.

About the Company

Community Health Systems

Operates acute care hospitals nationwide

Community Health Systems operates general acute care hospitals across 14 states, owning or leasing 71 facilities to deliver healthcare outside urban centers. Its main business is running hospital networks and providing medical and surgical services to patients, funded by payments from patients, insurers, and government programs like Medicare and Medicaid. The company also offers management services to its affiliates through a professional services corporation. Its workflow centers on developing and operating healthcare delivery systems, supporting a wide range of needs from emergency care to specialized treatments. The goal is to help people get well and live healthier by providing accessible non-urban and suburban hospital-based care while navigating a regulated, competitive US healthcare market.

Company size: 5,001-10,000
Company stage: IPO
Headquarters: Franklin, TN
Founded: 1985

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