Utilization Management Coordinator

HonorHealth•Virtual - Arizona, AZ

1d•Remote

About The Position

Under the direction of the Network Manager for Utilization Management, the Utilization Management Coordinator assists with administering utilization management functions, including organizing and prioritizing workflow, communicating with internal and external departments, interpreting and tracking critical information, following up, conducting research, and creating reports. The role primarily supports utilization management operations and payer communications to obtain admission approvals through clinical review and appeal processes. It also supports Care Coordination by helping optimize payer communications and workflow. The coordinator handles inbound faxes according to payer requirements, checks that approvals align with patient class, escalates conflicting payer communications, and communicates account discrepancies related to payer coverage or admission notifications. The role documents appropriately in EMR/EPIC and works with UM nurses on payer clinical-documentation requirements to secure the appropriate authorization level for inpatient or observation admissions. It also identifies and initiates concurrent denial documentation and workflows, including scheduling physician advisor peer-to-peer reviews with payers. The coordinator performs routine clerical and revenue-optimization work according to department workflows and productivity standards. The position works assigned work queues, monitors and processes payer faxes, uploads approvals, bed days, and denials to patient accounts, documents authorizations and communications in EMR/EPIC, and sends initial or continued-stay clinicals to payers using the required methods. The coordinator follows up on unsuccessful fax transmissions and deferred accounts, collaborates with payers and internal teams to secure approvals, facilitates clinical data requests, and coordinates concurrent denial resolution with nurses and physician advisors. The role also retrieves utilization management clinical requests, escalates patient calls to leadership, and may perform additional duties such as reports, research, meeting scribing, and new-hire onboarding.

Requirements

High school diploma or GED required.
One year of clerical support experience required.

Nice To Haves

Associate degree preferred.
One year of administrative support experience in a healthcare field preferred, such as case management, utilization review, medical insurance, medical office front desk, hospital business office, preservices, admitting, registration, billing, or collections.

Responsibilities

Organize and prioritize utilization management workflows and support related communications, tracking, follow-up, research, and reporting.
Work assigned work queues and perform routine clerical and revenue-optimization activities while meeting productivity standards.
Monitor RightFax daily, rename inbound payer faxes according to department conventions, and upload approvals, bed days, and denials to the appropriate patient accounts.
Document authorization, certification, and communications in EMR/EPIC according to department standards.
Send initial and continued-stay clinical documentation to payers using required methods and follow up on fax failures until resolved.
Follow up with payers on deferred accounts to obtain additional approved days.
Ensure approvals align with the current patient class and escalate payer communications that conflict with it.
Communicate account discrepancies involving payer coverage or admission notification issues to relevant Network departments.
Communicate with the Preservices team when patient coverage is terminated or unclear.
Collaborate with payers, UM nurses, and Care Coordination team members to secure approvals and support department business needs and revenue optimization.
Facilitate clinical data requests and document them appropriately.
Identify and initiate concurrent denial documentation and operational workflows.
Coordinate concurrent denial resolution with nursing and physician advisor teams, including facilitating payer peer-to-peer reviews as directed.
Retrieve utilization management clinical requests and handle them according to department standards.
Escalate patient calls to leadership and document them in EPIC/EMR.
Complete required compliance breach reporting and submit chart corrections when HIPAA breaches occur.
Communicate barriers and escalate issues.
Perform other assigned duties, which may include reports, research, meeting scribing, and new-hire onboarding.