Utilization Review Coordinator

Pioneer Human Services•Oak Harbor, WA

1d•$27 - $41

About The Position

The Utilization Review Coordinator reviews guest medical records for completeness and accuracy to ensure appropriate funding and authorizations are in place for timely, accurate payment. The role supports utilization management goals of controlling costs, improving revenue collection, and maintaining data integrity, and works closely with clinical, leadership, administrative, billing, management, utilization management, and finance staff. The coordinator applies utilization criteria and payer requirements, supports authorization and denial appeals, monitors utilization and authorization patterns, and coordinates funding-related issues. The role also collaborates with health plans and community partners to ensure services are covered and clients can access appropriate care in the least restrictive clinically appropriate setting. The position requires maintaining current knowledge of applicable federal and state regulations and providing excellent service to payers, vendors, and internal customers.

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 continuing treatment.
Monitor utilization patterns, including daily census, no-shows, and AMAs, and notify leadership of 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 managed care organizations (MCOs) to appeal denials.
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.
Help ensure clients can access services while preserving their right to the least restrictive environment appropriate to their clinical needs.
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 clinical staff to ensure accurate 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 appropriate 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.