Utilization Review Coordinator

Job Summary:

Intensive Specialty hospital is seeking a detail-oriented and motivated Utilization Management Review Coordinator to support the authorization process for continued patient care. This position plays a vital role in ensuring medical necessity and compliance with insurance guidelines while helping patients receive timely and appropriate services.

The UM coordinator will review medical records, coordinate with clinical and case management teams, and submit authorization requests to third-party payers. This role requires strong organizational skills, effective communication, and the ability to manage multiple priorities. Familiarity with managed care processes, InterQual, and ASAM criteria is preferred.

Key Responsibilities:

• Review patient charts and clinical documentation to evaluate medical necessity for continued care or services.
• Prepare and submit timely continuing authorization requests to insurance payers according to plan-specific guidelines.
• Collaborate with physicians, nurses, care managers, and clinical staff to ensure accurate documentation and authorization alignment with the patient's care plan.
• Apply InterQual and/or ASAM criteria to guide authorization requests.
• Monitor and follow up on submitted authorizations to avoid denials.
• Communicate effectively with insurance representatives to resolve issues related to approvals or denials.
• Maintain accurate and up-to-date documentation of all utilization review activities in the electronic health record (EHR).
• Remain current with payer policies, state and federal regulations, and evidence-based guidelines.
• Prioritize tasks to meet internal deadlines and external payer timeframes.
  
  
  

Qualifications:

• Experience: Clinical experience in acute care, managed care, or behavioral health preferred.
• Preferred Knowledge & Skills:
• Basic understanding of utilization review and case management processes.
• Familiarity with InterQual and/or ASAM guidelines.
• Knowledge of managed care principles and insurance authorization processes.
• Excellent attention to detail, organizational skills, and time management.
• Proficient in EHR systems and Microsoft Office (Word, Excel, Outlook).
• Strong written and verbal communication skills.