Utilization Review Coordinator

Pioneer Human Services • Spokane, WA

10d • $25 - $31

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 Coordinator (part-time weekends) 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. What We Offer At Pioneer, our employees are important. That's why we offer a Total Rewards package that includes compensation and benefits to support employees' health, security, and balance. The goal of utilization management is to control costs, improve revenue collection, and ensure data integrity. The Utilization Review Coordinator will critically examine guest medical records for completeness and accuracy to ensure appropriate funding and authorizations are in place for timely and accurate payment. This position works closely with clinical, leadership and administrative staff to ensure Pioneer receives accurate and timely payment for services provided.

Requirements

• Associate's degree in health care, business, or related field or two years of experience in Utilization Management/Medical Administrative Assistant
• 2 year of experience working with individuals with behavioral health conditions
• 2 years of experience working in substance use or mental health fields

Nice To Haves

• Bachelor's degree or higher in health care, business or related field
• Experience in Medical billing, data entry, invoicing
• Experience working in a residential treatment facility

Responsibilities

• Reviews treatment plans to ensure proper documentation, continuity of care, and compliance
• Reviews client records using utilization criteria to ensure medical necessity and determine need for continuing treatment
• Monitors utilization patterns including daily census, no-shows, and AMAs and notifies leadership of potential utilization issues
• 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
• Negotiates length of stay with payers
• Collaborates with clinical team to ensure accuracy of payer information, placement, clinical status, and discharge needs
• Coordinates with health plan organizations, hospitals, doctors, and pharmacists to ensure services are covered and to improve treatment outcomes
• Composes and sends professional communication related to medical records and case coordination
• 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 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

Benefits

• New hires for this position typically start between $25.01 and $31.26 hourly/annually , depending on factors such as work location, experience, qualifications, skills, competencies, internal equity, and market conditions
• Retirement plan: Pioneer contributes 3.5% of an employees' annual compensation into retirement plans. An additional 3.5% match is offered to those who contribute 6% on their own.
• Employee recognition programs: gift cards, additional time off, weekend getaways and more.
• Public transportation discount.
• Employee assistance program (EAP).

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 501-1,000 employees