Clinical Utilization Review Specialist

Oceans Healthcare; Baton Rouge (LA); On-site; USD 55,000 - 75,000; Full time

Job summary

Oceans Healthcare is seeking a dedicated Utilization Review Coordinator to manage inpatient, partial hospitalization, and outpatient utilization review activities. You will conduct concurrent reviews, coordinate with third-party payers, and ensure timely discharge planning while maintaining documentation for compliance and quality care.

You will interact with clinical staff to support level and intensity of service, participate in treatment teams, and handle pre-certifications, denials, and

Qualifications

• Associate degree in healthcare or bachelor's in social services preferred.
• At least one year psychiatric/chemical dependency experience.
• Experience with regulatory and fiscal reimbursement processes.
• Strong written communication skills.
• CPR certification and de-escalation training required.

Responsibilities

• Identifies under-use, over-use and inefficient use to ensure quality patient care in a cost-effective manner.
• Reviews inpatient, partial hospitalization, and outpatient records for admission necessity, continued stay, and discharge.
• Reports findings to disciplines and committees; notifies staff of deficiencies for timely action.
• Coordinates flow of information between physicians, staff and payers for reimbursement.
• Attends treatment team meetings to obtain pre-certification and ongoing requirements.
• Maintains abstracts and notifies payers of reimbursement issues.
• Initiates and completes appeals for reimbursement denials; informs inpatients of denials.
• Reports monthly Hospital Issued Notices of Non-coverage to QIO.
• Conducts audits as needed and ensures authorization/denied information is up to date.

Skills

Assertive communication

CD-psych treatment

Discharge planning

Writing skills

Reimbursement knowledge

Patient advocacy

Data analysis

Time management

De-escalation training

Team collaboration

Education

Associate degree in healthcare

Bachelor's degree in social services

Job description

Oceans Healthcare is seeking a dedicated Utilization Review Coordinator to manage inpatient, partial hospitalization, and outpatient utilization review activities. You will conduct concurrent reviews, coordinate with third-party payers, and ensure timely discharge planning while maintaining documentation for compliance and quality care.

You will interact with clinical staff to support level and intensity of service, participate in treatment teams, and handle pre-certifications, denials, and