Care Coordination & Utilization Review Specialist

TimeTrex (TimeTrex Software Inc.); Arcata (CA); On-site; USD 85,000 - 115,000; Full time

Job summary

Mad River Community Hospital is seeking an Utilization Review Coordinator to join our dedicated team. You will facilitate utilization review activities in an inpatient setting and support discharge planning and transitional care for patients of our hospital.

You will collaborate with health plans and care teams to ensure appropriate resource use and timely discharge, conducting clinical reviews for services requiring authorization and communicating with insurers for approvals.

Qualifications

• Bachelor's or Master's degree in Nursing, Social Work, Sociology, or related field.
• Current clinical licensure, ideally RN or LCSW.
• Two to five years of acute care clinical experience.
• Working knowledge of DRG classification, CPT coding, and InterQual.

Responsibilities

• Collaborates with health plans and care teams to optimize resource use and timely discharge.
• Provides clinical review for services requiring authorization (acute inpatient, SNF, rehab, home health).
• Communicates with insurance representatives to ensure appropriate authorization for care.
• Develops discharge and transitional care plans based on patient and social needs assessment.
• Articulates legal issues related to patient care and issues denial letters per procedures.

Skills

RN/LCSW licensure

Clinical communication

DRG knowledge

CPT coding

InterQual knowledge

Education

Bachelor's or Master's degree in Nursing or Social Work

Tools

EMR systems

Job description

Mad River Community Hospital is seeking an Utilization Review Coordinator to join our dedicated team. You will facilitate utilization review activities in an inpatient setting and support discharge planning and transitional care for patients of our hospital.

You will collaborate with health plans and care teams to ensure appropriate resource use and timely discharge, conducting clinical reviews for services requiring authorization and communicating with insurers for approvals.