Utilization Review Administrator

Pioneer Human Services•Spokane, WA

4d•Onsite

About The Position

If you are looking for employment with a purpose where you can help improve the daily lives of the members of your community, then consider a career with Pioneer Human Services! We are currently looking for a Utilization Review Administrator with a passion for human services. This is an exciting opportunity to be involved with an organization focused on a transformative path towards social change, creating pathways for rehabilitation, reintegration, and redemption. Who we are – Our Mission We empower justice-involved individuals to overcome adversity and reach their full potential. For over 60 years, we have proudly serviced our clients with professionalism and empathy. We are a nationally recognized non-profit with 35+ locations across Washington state that provided a chance for change to over 9,500 individuals in 2024.

Requirements

High school diploma/GED
1 year of experience working in substance use, medical or mental health fields
1 year of experience working with individuals with behavioral health conditions

Nice To Haves

Associates Degree in health care, business, or related field
1-year administrative experience in the healthcare or related field (i.e. billing, data entry, invoicing)
Experience working in a residential treatment facility

Responsibilities

Monitors utilization patterns including daily census, no-shows, and AMAs and notifies leadership of potential utilization issues
Reviews bed boards daily to ensure accuracy
Ensures initial authorizations, episodes, and bed boards are completed in a timely and accurate manner
Monitors, tracks, and analyzes required reports
Maintains applicable UR documentation in Electronic Medical Record (EMR)
Conducts peer-to-peer review with MCO to appeal denials
Submits appeals for denied authorizations with applicable clinical, demographic, and payer information
Coordinates, monitors, and tracks resolution of revenue cycle tickets to help resolve funding and other related, non-clinical, client issues
Ensures clients have access to services while ensuring the client’s right to be in the least restrictive environment as clinically appropriate
Understands and applies MCO, CMS, and insurance requirements for pre-authorization, authorization, concurrent, retrospective, and peer-to-peer review for individuals admitted under voluntary treatment status
Ensures excellent customer service is provided to payers, vendors, and internal customers
Maintains access to Quick Mar, EHR, payer portals and other required systems
Composes and sends professional communication related to medical records and case coordination
Works with UR Coordinator to ensure length of stay for each program is within authorization duration
Monitors and provides appropriate staff updates for authorizations and length-of-stay; assists with transition for continued stays, discharges, or transfers
Collaborates and partners with billing, clinical staff, management, UM team, and finance to ensure data accuracy, operational efficiency, timely financial collection, and adequate task coverage
Maintains working knowledge and collaborative relationships with community partners and resources
Promotes and models teamwork and collaboration with coworkers
Maintains quality of care consistent with or exceeding standards set by federal, state, local, internal, and contract requirements
Adheres to professional and ethical standards for behavioral health services
Develops internal UR policies and procedures
Guides staff in proper completion of clinical documentation to ensure accuracy and quality client care
Maintains current knowledge of federal and state regulations for Medicaid, Medicare, private insurance/managed care, and other related industry programs and practices
Assists with training staff to ensure operational efficiency