Lead Utilization Management Coordinator

WVU Medicine; Northern (KY); Hybrid; USD 90,000 - 120,000; Full time

Job summary

WVU Medicine in the United States is seeking a Lead Utilization Management Coordinator to drive strategic oversight, execution, and denial mitigation for timely authorizations and optimized reimbursement. You will mentor UM coordinators, partner with Physician Advisors and Clinical Appeals, and lead process improvements as an SME for UM.

The role emphasizes proactive denial-prevention solutions, educational initiatives for staff, and collaboration across revenue cycle and clinical care to ensure

Qualifications

• Current Registered Nurse license issued by the state in which services will be provided or current multi-state RN license through the Enhanced NLC.
• Four (4) years clinical experience in a hospital setting.
• Five (5) years Utilization Review and/or Clinical Appeals and/or case management experience.

Responsibilities

• Coaching and mentoring team members; identify skill gaps; provide real-time feedback and track action items.
• Monitor day-to-day operations; ensure deadlines and staffing coverage.
• Produce and communicate performance improvement opportunities; ensure quality assurance and SOP adherence.
• Act as SME: respond to staff questions; orient new staff; support education and process initiatives.
• Assess referred concurrent denials to determine next steps: peer-to-peer, billing status changes, or clinical information requests; refer cases as needed.

Skills

Verbal and written communication

Interpersonal skills

Attention to detail

Medical terminology

Payor concepts

Computers

Customer service

Education

RN license (state or multi-state eNLC)

Bachelor's Degree in Nursing

Job description

Welcome! We’re excited you’re considering an opportunity with us! The Lead Utilization Management Coordinator (UMC) assists in driving the strategic oversight, execution, and mitigation of concurrent denials to secure timely authorizations, prevent costly and lengthy appeals, and optimize institutional reimbursement. This role functions as an advanced clinical and operational leader with acute knowledge of utilization management (UM), medical necessity, patient status determination, payor behaviors, and complex appeal strategies. Serving as an SME for operational integrity, the Lead UMC assists in quality assurance frameworks and continuous monitoring protocols to track team performance and compliance. Serving as a crucial bridge across the revenue cycle and clinical care, the Lead UMC mentors the utilization management coordinators. They partner closely with the Physician Advisor team and Clinical Appeals to participate in process improvements as an SME for the UMC role. The Lead UMC also works towards proactive denial-prevention solutions and high-impact educational initiatives for staff.

Minimum Qualifications

• Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).
• Four (4) years clinical experience in a hospital setting.
• Five (5) years Utilization Review and/or Clinical Appeals and/or case management experience.

Preferred Qualifications

• Bachelor’s Degree in Nursing.

Core Duties and Responsibilities

1. Coaching and mentoring: Assist in developing team members skills and active identification of weaknesses through:
   • Observation of daily workflows and perform skill gap analyses.
   • Provide real-time feedback – address errors immediately with corrective feedback.
   • Track action items on weekly meeting grid.
2. Assisting and monitoring day-to-day operations:
   • Assure that daily deadlines are met.
   • Review of staffing to ensure adequacy (vacation / holiday coverage).
3. Reporting; acting as a liaison between the team and leadership:
   • Performance Improvement – reporting opportunities for improvement identified in the day-to-day processes.
   • Quality Assurance – reporting any backslide in standard operating procedures.
   • KPI tracking – reporting team output against established goals.
4. Acting as a subject matter expert:
   • Act as the daily point person for staff questions and concerns.
   • Oversight over orientation of new staff members.
   • Assist with educational needs and new process initiatives.
   • Assist in document control – yearly review of staff resources / documents / process flows.
5. Assess all referred concurrent denials to determine appropriate next steps including, but not limited to, requesting peer to peer, determining need to change billing status, requesting additional clinical information from the Utilization Review RNs, and referring cases to the Clinical Appeals team.
6. Reviews medical record documentation and provides recommendations for denial management based on clinical expertise and payor behaviors.
7. Partners with leadership and contracting to develop most beneficial language for payor agreements and contracts.
8. Collaborates with internal and external physician advisor functions by coordinating and facilitating peer to peer assignments.
9. Collaborates with UR coordinators, clinical appeals, and physician advisors to prevent and manage concurrent denials.
10. Advocates for the patient and hospital with insurance companies to optimize reimbursement and hospital stay coverage.
11. Manages all assigned processes in compliance with the Medicare Conditions of Participation including, but not limited to the W2/121 billing/self-denial process, patient communication regarding UR committee determinations, and communication with external entities as required in the federal and state regulations.
12. Analyzes key metrics for projects as assigned.
13. Maintains working knowledge of payor requirements.
14. Partner with Clinical Appeals team to ensure aligned process for front and back end denial management.
15. Provide highly effective reconsideration clinicals to payors in order to prevent denials.
16. Facilitates professional communication to ensure the authorization process is completed in a patient centered manner with adherence to quality and timeline standards.
17. Maintains effective and efficient processes for determining appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers.
18. Maintains knowledge and understanding of applicable federal regulations and Conditions of Participation.
19. Actively participates in process improvement initiatives, working with a variety of departments and multidisciplinary staff.
20. Effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment.
21. Collaborates with other members of the interdisciplinary team as outlined in the system UM Plan.
22. Coordinates communication with physicians and collaborates to ensure appropriate patient status.
23. This individual identifies, develops, and provides orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis.
24. Consistently demonstrate ability to serve as a role model and change agent by promoting the concept of teamwork and the revenue cycle process continuum of high performing teams.

Physical Requirements

• Office work which includes sitting for extended periods of time.
• Must have reading and comprehension ability.
• Visual acuity must be within normal range.
• Must have the ability to communicate effectively.
• Must have manual dexterity to operate keyboards, fax machines, telephones and other business equipment.

Working Environment

• Office work which includes sitting for extended periods of time.
• Maintains confidential home office space.
• Required weekends and holidays as assigned.

Skills & Abilities

• Effective verbal and written communication skills.
• Strong interpersonal skills.
• Strong attention to detail.
• Knowledge of medical terminology required.
• Knowledge of third party payers required.
• Ability to use tact and diplomacy in dealing with others.
• Working knowledge of computers.
• Excellent customer service and telephone etiquette.

Additional Job Description

• Scheduled Weekly Hours: 40
• Shift: Exempt/Non-Exempt: United States of America (Exempt)
• Company: SYSTEM West Virginia University Health System
• Cost Center: 553 SYSTEM Utilization Review

The West Virginia University Health System is West Virginia’s largest health system and the state’s largest employer with more than 3,400 licensed beds, 4,600 providers, 35,000 employees, and $7 billion in total operating revenues. The Health System is comprised of 25 hospitals – including J.W. Ruby Memorial Hospital, an 880-bed academic medical center, and the 150-bed WVU Medicine Children’s Hospital in Morgantown, West Virginia – and five institutes. To learn more, visit WVUMedicine.org.