Utilization Review Coordinator

Summary

The Utilization Review Coordinator will report directly to the Senior Director of RCM. This team member will be responsible for handling pre-certifications, authorizations, retro-authorizations, appeals, medical records requests, and chart auditing duties that coincide with accurate reporting of each client’s clinical level of care, program, and treatment days utilized. The Utilization Review Coordinator should be a subject matter expert on payor requirements and expectations. This role requires strategic planning and coordination with on-site providers and the revenue cycle department to obtain optimal utilization review outcomes.

Responsibilities

• Utilization Review on Behalf of the Clinics:
  • Prescreen referrals to project/anticipate authorizations. Provide recommendations regarding level of care/services and treatment planning.
  • Conduct live reviews with payors and level of care chart reviews, conceptualizing the clinical presentation and care needs and applying medical necessity guidelines and /or LOCUS to compel authorization.
  • Clinically negotiate authorization outcomes with the payor, collaborating in advance with the primary treating clinicians.
  • Coordinate Peer-to-Peer (P2P) Review preparation and assist with scheduling. Provide guidance and training to clinicians on completing P2P reviews.
  • Establish internal authorization or denial determinations for No Authorization Required (NAR) requests.
  • Establish post denial appeal response recommendations.
  • Obtain portal access to any utilization review portals for an efficient and scalable process.
• Interdepartmental Relations and Communication:
  • Coordinate with the clinical team on requests with clinically weaker presentations.
  • Coordinate all concurrent insurance reviews with clinicians and medical team.
  • Provide guidance on specific interventions or areas on which to focus to result in maximum authorized days.
  • Provide ongoing feedback and recommendations for improvement to meet payor medical necessity guidelines.
  • Attend and participate in daily huddles/weekly rounds as the payor expert to ensure appropriate authorization outcomes and provide ongoing education regarding payor requirements.
  • Communicate with relevant parties at the facility and in RCM about any issues with coverage or denials, facilitating client notifications as needed.
  • Partner with intake, utilization review, and finance for best practices in overarching company goals related to RCM.
  • Timely completion of the Denial Notification process.
• Accurate Data Entry:
  • Document deficiencies for identification on the daily reporting