Utilization Review Coordinator

We are seeking a Utilization Review (UR) Coordinator to join our team. The UR Coordinator is a healthcare professional who bridges the gap between medical providers, patients, and insurance companies. They evaluate medical records to ensure that patient treatments meet established clinical guidelines, secure insurance authorizations, and manage healthcare costs while maintaining quality care.

Essential Duties:

·         Prior Authorization & Certification: Submitting clinical documentation to health insurance to approve planned procedures, hospital admissions, or continued stays

·         Medical Necessity Evaluation: Reviewing patient charts to ensure the level of care matches the patient's condition and meets both regulatory and insurance standards

·         Compliance & Auditing: Ensuring all medical documentation adheres to HIPAA and insurance regulations

·         Liaison Duties: Acting as a central point of contact between clinical staff, billing departments, and third-party payers

·         Treatment Team Collaboration: Attends interdisciplinary treatment team to gather clinical justifications, track therapy progress, and align care plans with approved insurance days

·         Length-of-Stay Tracking: Monitors how long patients stay in the facility against approved insurance timelines to reduce financial penalties

·         Insurance Alignment: Advises the clinical team on what documentation is missing or needed to justify continued care to the insurance company

·         Denial Analysis: Reviews insurance denial letters to pinpoint the exact contractual or clinical reason why the level of care was rejected

·         Peer-to-Peer Coordination: Schedules and prepares facility psychiatrists for immediate telephonic reviews with insurance medical directors

·         Expedited Appeals Submission: Drafts and submits urgent clinical appeal packets within tight, state-mandated 24 to 72-hour windows for active patients

·         Perform other duties as per the requirements of the organization.

Education and/or Licensure – Highschool Diploma/GED required. Bachelor’s degree preferred.

Experience – Experience in behavioral healthcare preferred.

Additional Requirements – Must possess or obtain a valid CPR certification and de-escalation training before completing new hire orientation.

Knowledge, Skills, and Abilities:

·         Exceptional verbal and written skills to translate complex insurance rules to therapists, psychiatrists, and families

·         Ability to review complex medical records to extract data that proves medical necessity

·         Strong negotiation skills to defend treatment plans during difficult conversations with insurance medical directors

·         Organizational skills

·         Proven expertise solving problems

·         Proficiency in Microsoft Office Suite and other related software to perform necessary tasks

Physical Requirements:

·         Stationary Position: Substantial time spent sitting at a desk and operating a computer.

·         Office Mobility: Ability to walk, reach, and move around an office environment.

·         Lifting/Carrying: Occasional, light lifting, usually limited to 10–25 lbs.

401K, Medical/Dental insurance, FMLA and Short-Term Disability

• Health Insurance
• Vision Insurance
• Dental Insurance
• 401K Retirement Plan
• Healthcare Spending Account
• Dependent Care Spending Account
• PTO Plan with Holiday Premium Pay
• Life Insurance (Supplemental Life, Term, and Universal plans are also available.)
• Short and Long-Term Disability (with additional buy-in opportunities)