Utilization Review Coordinator (On-Site)

Pioneer Human Services•Everett, WA

5d•Onsite

About The Position

The Utilization Review Coordinator supports utilization management by examining guest medical records for completeness and accuracy, ensuring appropriate funding and authorizations are in place for timely and accurate payment. The position works closely with clinical, leadership, and administrative staff to support accurate payment for services, control costs, improve revenue collection, and maintain data integrity. The role also helps ensure clients have access to services in the least restrictive environment clinically appropriate.

Requirements

Associate’s degree in health care, business, or a related field, or two years of experience in Utilization Management/Medical Administrative Assistant.
Two years of experience working with individuals with behavioral health conditions.
Two years of experience working in substance use or mental health fields.

Nice To Haves

Bachelor’s degree or higher in health care, business, or a related field.
Experience in medical billing, data entry, or invoicing.
Experience working in a residential treatment facility.

Responsibilities

Review treatment plans for proper documentation, continuity of care, and compliance.
Review client records using utilization criteria to assess medical necessity and the need for continued treatment.
Monitor utilization patterns, including daily census, no-shows, and AMAs, and notify leadership about potential issues.
Monitor, track, and analyze required reports.
Maintain applicable utilization review documentation in the Electronic Medical Record (EMR).
Conduct peer-to-peer reviews with MCOs to appeal denials and submit appeals for denied authorizations with applicable clinical, demographic, and payer information.
Coordinate, monitor, and track revenue cycle tickets to help resolve funding and other related non-clinical client issues.
Apply MCO, CMS, and insurance requirements for pre-authorization, authorization, concurrent, retrospective, and peer-to-peer review for individuals admitted under voluntary treatment status.
Provide excellent customer service to payers, vendors, and internal customers.
Maintain access to Quick Mar, EHR, payer portals, and other required systems.
Negotiate length of stay with payers.
Collaborate with the clinical team to ensure accuracy of payer information, placement, clinical status, and discharge needs.
Coordinate with health plan organizations, hospitals, doctors, and pharmacists to ensure services are covered and improve treatment outcomes.
Compose and send professional communications related to medical records and case coordination.
Monitor authorizations and length of stay, provide staff updates, and assist with transitions for continued stays, discharges, or transfers.
Collaborate with billing, clinical staff, management, the UM team, and finance to support data accuracy, operational efficiency, timely financial collection, and adequate task coverage.
Maintain working knowledge of and collaborative relationships with community partners and resources.
Promote and model teamwork and collaboration with coworkers.
Maintain current knowledge of federal and state regulations for Medicaid, Medicare, private insurance/managed care, and related industry programs and practices.
Assist with training staff to support operational efficiency.