Utilization Management Coordinator

Corewell Health • Southfield, MI

14h • Onsite

About The Position

Scope of Work: This role includes accountability for utilization review (UR) and may include admission, concurrent, and retrospective reviews. Coordinates activities involved in the certification, recertification, and concurrent appeals process, conducting referrals for 2nd level review, as needed. Ensures timely communication with payers based on adequate and complete documentation received by the physician/provider and utilization reviews. Initiates concurrent appeals to address patient class/status downgrades or clinical denials related to medical necessity. Participates within the department to meet expected objectives and outcomes. Meets or exceeds expectations related to behavior and performance. Meets individual and departmental objectives established for Quality, Satisfaction, Growth and Financial Success. Conducts timely and accurate utilization reviews, as assigned, using organization-approved UR criteria. Works closely with physician advisors and medical staff to ensure appropriate level of care, including obtaining physician orders for patient class changes when needed. Refers cases, as defined, for 2nd level medical necessity review. Maintains daily contact with payers to obtain authorization and reauthorization information and addresses concurrent denials and/or audit requests. Provides UR and clinical documentation is adequate and complies with payer requirements. Schedules next review/follow-up reviews as required in accordance with organizational policy and procedure and payer requests. Routinely collaborates with the System Clinical Appeals and Revenue Cycle departments to expedite billing and appeals processes. Maintains and monitors assigned work queues within the Electronic Medical Record.

Requirements

• Associate's Degree Associates or technical degree.
• 2 years of relevant experience
• 2 years of experience in clinical/hospital setting.
• Hospital utilization review/utilization management experience.

Nice To Haves

• Bachelor's Degree in nursing or related field.
• Clinical appeals experience.
• Registered Nurse (RN) - State of Michigan Upon Hire

Responsibilities

• Accountability for utilization review (UR) and may include admission, concurrent, and retrospective reviews.
• Coordinates activities involved in the certification, recertification, and concurrent appeals process, conducting referrals for 2nd level review, as needed.
• Ensures timely communication with payers based on adequate and complete documentation received by the physician/provider and utilization reviews.
• Initiates concurrent appeals to address patient class/status downgrades or clinical denials related to medical necessity.
• Participates within the department to meet expected objectives and outcomes.
• Meets or exceeds expectations related to behavior and performance.
• Meets individual and departmental objectives established for Quality, Satisfaction, Growth and Financial Success.
• Conducts timely and accurate utilization reviews, as assigned, using organization-approved UR criteria.
• Works closely with physician advisors and medical staff to ensure appropriate level of care, including obtaining physician orders for patient class changes when needed.
• Refers cases, as defined, for 2nd level medical necessity review.
• Maintains daily contact with payers to obtain authorization and reauthorization information and addresses concurrent denials and/or audit requests.
• Provides UR and clinical documentation is adequate and complies with payer requirements.
• Schedules next review/follow-up reviews as required in accordance with organizational policy and procedure and payer requests.
• Routinely collaborates with the System Clinical Appeals and Revenue Cycle departments to expedite billing and appeals processes.
• Maintains and monitors assigned work queues within the Electronic Medical Record.

Benefits

• Comprehensive benefits package to meet your financial, health, and work/life balance goals. Learn more here.
• On-demand pay program powered by Payactiv
• Discounts directory with deals on the things that matter to you, like restaurants, phone plans, spas, and more!
• Optional identity theft protection, home and auto insurance, pet insurance
• Traditional and Roth retirement options with service contribution and match savings
• Eligibility for benefits is determined by employment type and status

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree