Utilization Review Coordinator

Pioneer Human Services • Sedro-Woolley, WA

4d • $27 - $41 • 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 Coordinator 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

• 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

• Medical
• Flexible spending
• Dental
• Vision
• Life
• AD&D
• Disability
• Dependent Daycare Flexible Spending
• Tuition assistance (100% for bachelor's, 50% for graduate programs)
• Retirement plan (3.5% annual compensation contribution, plus 3.5% match for 6% individual contribution)
• Employee recognition programs
• Public transportation discount
• Employee assistance program (EAP)

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree