Utilization Review Coordinator

Rimrock Foundation•Billings, MT

7d•Hybrid

About The Position

Manages the administrative components of utilization review for all levels of care and all payers. Serves as the organization's central point of accountability for authorization tracking, assuring that prior authorizations, continued stay reviews, requests for information, reconsiderations, and retrospective reviews are complete and submitted within required timeframes. This is a non-clinical position: the UR Coordinator does not determine medical necessity or author clinical content, but requests clinical documentation from clinical staff according to the department's provider priority list, assembles and reviews submission packets for completeness, submits them, and tracks each authorization from admission through discharge and billing. Partners with the business office on authorization-related denials and unauthorized days, and with clinical leadership on clinical input and appeals. Assures adherence to Montana Medicaid and BHDD utilization management requirements, payer-specific requirements, and federal regulations including HIPAA and 42 CFR Part 2. Positively represents the organization and promotes Rimrock's Mission to the community.

Requirements

High school diploma or equivalent required
Minimum of two years' experience in healthcare billing, prior authorizations, insurance verification, medical records, or a medical office setting.
Organization, deadline and caseload management, written and verbal communication, attention to detail, records management, and problem-solving skills.
Working knowledge of medical terminology and payer authorization processes.
Ability to work independently, prioritize competing deadlines, and follow up professionally with clinical staff and payers.
Computer skills and proficiency with electronic health record systems, payer portals, and Microsoft software including Word, Excel and Outlook.
Complies with all HIPAA and 42 C.F.R. Part 2 regulations relating to privacy, security, and confidentiality.
Safeguards confidential information of patients, employees, and business operations
Knows and understands emergency procedures and completes incident reports within 24 hours of event with detailed information.

Nice To Haves

Associate degree in health information management, medical billing, business, or a related field preferred.
Experience in behavioral health or substance use disorder treatment, and familiarity with Montana Medicaid, ASAM levels of care, and the BHDD Medicaid Services Provider Manual preferred.
Certification such as Certified Professional Biller (CPB), Certified Revenue Cycle Specialist (CRCS), or Registered Health Information Technician (RHIT) preferred.

Responsibilities

Maintains the UR tracker as the single record of every authorization across Medicaid and commercial payers, including authorized dates, units, next deadlines, assigned clinical staff, status, and outcomes.
Monitors authorization end dates and calendars all required deadlines, including continued stay submission windows, request for information responses, peer-to-peer and desk review requests, and retrospective review windows.
Verifies payer eligibility and authorization requirements at admission in partnership with admissions and billing.
Requests clinical documentation from clinical staff with clear due dates, assigning each request according to the department's provider priority list, which ranks available clinical staff by credential level appropriate to the request and current availability.
Follows up on outstanding clinical documentation requests; reassigns to the next available provider on the priority list and escalates unresolved requests to the Assistant Controller and the Director of Clinical Services.
Schedules peer-to-peer reviews between payer reviewers and the appropriate Rimrock clinician or physician.
Assembles authorization and continued stay packets from the electronic health record and reviews them for completeness against payer requirements; does not create clinical content or determine medical necessity.
Submits authorization requests through payer portals, including the Montana Medicaid utilization review contractor portal, and by fax and telephone within required timeframes.
Assures that documentation supporting auto-authorized services is submitted within the timeframe required by the payer.
Logs determinations, requests for information, and denials; routes requests for information to the author of the original documentation and submits responses within required timeframes.
Prepares and files written requests for reconsideration, including peer-to-peer and desk reviews, and tracks each to resolution.
At discharge, reconciles final authorized dates with actual dates of service, closes the case with the payer or review contractor, and notifies billing of any unauthorized days before claims are submitted.
Works authorization-related denials with the accounts receivable team, identifies root causes, and recommends process corrections.
Submits retrospective review requests when patients become Medicaid eligible after admission.
Maintains written payer requirements, contacts, templates, and desk procedures; cross-trains a designated backup.
Monitors BHDD Medicaid provider manual updates and payer utilization review policy changes and communicates changes to business office and clinical staff.
Assures utilization review data required for quality improvement, state, and payer reporting is accurate and submitted on schedule.
Provides timely and thorough follow-up with internal and external customers.
Obtains feedback from patients regarding their perceptions of the service provided to them and utilizes this information to improve service delivery.
Serves on committees or process improvement teams to assist in improving quality/customer satisfaction, as assigned.
Models professionalism by addressing others with appropriate actions, appearance and communication.
Prepares and presents monthly utilization review performance measures, including authorized days lost to late or missed submissions, on-time submission rate, request for information turnaround, technical denials by cause, appeal outcomes, and auto-authorization quality scores.
Assures that information is collected, organized, reported and used to improve the quality of systems and services.
Reviews denial and unauthorized-day trends with the Assistant Controller and the Director of Clinical Services and recommends corrective action.
Self-audits auto-authorization submissions against payer quality criteria and escalates any change in the organization's rating.
Assures the UR tracker is current and reviewed weekly so that no authorization, request for information, or appeal deadline is missed.
Ensures compliance, regulatory and quality management standards are met.
Performs self-quality monitoring in order to develop and execute plans to meet established goals.
Other duties as assigned.