Utilization Review Administrator (on-site)

Pioneer Human Services; Spokane (WA); On-site; USD 27,000 - 34,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Flexible Spending Account (FSA)

Dependent Care FSA

Life insurance

AD&D insurance

Disability coverage

Front-Loaded Tuition Assistance

Retirement Plan

Employee recognition programs

Public transportation discounts

Employee Assistance Program (EAP)

Job summary

Pioneer Human Services is seeking an Utilization Review Administrator to help control costs, improve revenue collection, and ensure data integrity on-site in Spokane, WA. You will review medical records for accuracy to secure timely payments and work with clinical, leadership and administrative staff.

The role requires 1 year in behavioral health settings and 1 year of related experience, with a focus on pre-authorization and billing processes.

Qualifications

• High school diploma or GED required.
• At least 1 year of experience in substance use, medical, or mental health fields.
• At least 1 year of experience working with individuals with behavioral health conditions.
• Preferred: Associate degree in health care, business, or related field.
• Preferred: 1 year administrative experience in healthcare or related field.
• Preferred: experience in a residential treatment facility.

Responsibilities

• Monitor utilization patterns and notify leadership of issues.
• Review bed boards daily for accuracy.
• Ensure initial authorizations, episodes, and bed boards are timely.
• Analyze required reports and maintain UR documentation.
• Conduct peer-to-peer review with MCO to appeal denials.
• Submit appeals for denied authorizations with required info.
• Coordinate revenue cycle tasks for funding and non-clinical issues.
• Collaborate with billing, clinical, and finance teams to ensure data accuracy.

Skills

Detail oriented

Communication

Teamwork

Education

High school diploma/GED

Associate degree in health care or related field

Job description

Description

If you are looking for employment with a purpose where you can help improve the daily lives of the members of your community, then consider a career with Pioneer Human Services! We are currently looking for a Utilization Review Administrator (on-site) with a passion for human services. This is an exciting opportunity to be involved with an organization focused on a transformative path towards social change, creating pathways for rehabilitation, reintegration, and redemption. Who we are – Our Mission We empower justice-involved individuals to overcome adversity and reach their full potential. For over 60 years, we have proudly serviced our clients with professionalism and empathy. We are a nationally recognized non-profit with 35+ locations across Washington state that provided a chance for change to over 9,500 individuals in 2024. What We Offer At Pioneer, our employees are important. That's why we offer a Total Rewards package that includes compensation and benefits to support employees' health, security, and balance.

Compensation

New hires for this position typically start between $19.86 and $24.82 hourly, depending on factors such as work location, experience, qualifications, skills, competencies, internal equity, and market conditions. While the full pay range is provided to support pay transparency, individual compensation will vary within the range based on these factors.

Benefits That Invest In You

At Pioneer, we offer a comprehensive benefits package designed to support your health, financial well-being, and continued growth.

Health & Wellness Benefits

• Medical coverage
• Dental coverage
• Vision coverage
• Flexible Spending Account (FSA)
• Dependent Care Flexible Spending Account

Financial Protection

• Employer-provided life insurance
• Accidental Death & Dismemberment (AD&D) insurance
• Disability coverage

Invest in Your Future

• Front-Loaded Tuition Assistance
• Retirement Plan
• Employee recognition programs
• Public transportation discounts
• Employee Assistance Program (EAP)

Benefit eligibility, coverage, contributions, and program provisions are subject to the terms of the applicable benefit plans and policies.

What you'll do

As the Utilization Review Administrator you will help control costs, improve revenue collection, and ensure data integrity. The Utilization Review (UR) Administrator critically examines guest medical records for completeness and accuracy to ensure appropriate funding and authorizations are in place for timely and accurate payment. This position works closely with clinical, leadership and administrative staff to ensure Pioneer receives accurate and timely payment for services provided.

Primary/essential Duties And Responsibilities Are But Not Limited To

• Monitors utilization patterns including daily census, no-shows, and AMAs and notifies leadership of potential utilization issues
• Reviews bed boards daily to ensure accuracy
• Ensures initial authorizations, episodes, and bed boards are completed in a timely and accurate manner
• Monitors, tracks, and analyzes required reports
• Maintains applicable UR documentation in Electronic Medical Record (EMR)
• Conducts peer-to-peer review with MCO to appeal denials
• Submits appeals for denied authorizations with applicable clinical, demographic, and payer information
• Coordinates, monitors, and tracks resolution of revenue cycle tickets to help resolve funding and other related, non-clinical, client issues
• Ensures clients have access to services while ensuring the client’s right to be in the least restrictive environment as clinically appropriate
• Understands and applies MCO, CMS, and insurance requirements for pre-authorization, authorization, concurrent, retrospective, and peer-to-peer review for individuals admitted under voluntary treatment status
• Ensures excellent customer service is provided to payers, vendors, and internal customers
• Maintains access to Quick Mar, EHR, payer portals and other required systems
• Composes and sends professional communication related to medical records and case coordination
• Works with UR Coordinator to ensure length of stay for each program is within authorization duration
• Monitors and provides appropriate staff updates for authorizations and length-of-stay; assists with transition for continued stays, discharges, or transfers
• Collaborates and partners with billing, clinical staff, management, UM team, and finance to ensure data accuracy, operational efficiency, timely financial collection, and adequate task coverage
• Maintains working knowledge and collaborative relationships with community partners and resources
• Promotes and models teamwork and collaboration with coworkers
• Maintains quality of care consistent with or exceeding standards set by federal, state, local, internal, and contract requirements
• Adheres to professional and ethical standards for behavioral health services
• Develops internal UR policies and procedures
• Guides staff in proper completion of clinical documentation to ensure accuracy and quality client care
• Maintains current knowledge of federal and state regulations for Medicaid, Medicare, private insurance/managed care, and other related industry programs and practices
• Assists with training staff to ensure operational efficiency

What you'll bring

• High school diploma/GED
• 1 year of experience working in substance use, medical or mental health fields
• 1 year of experience working with individuals with behavioral health conditions

Preferably you'll bring

• Associates Degree in health care, business, or related field
• 1-year administrative experience in the healthcare or related field (i.e. billing, data entry, invoicing)
• Experience working in a residential treatment facility

EEO

Pioneer human services is an equal opportunity employer of minorities/women/individuals with disabilities/protected veterans and does not unlawfully discriminate under federal, state, or local laws. All qualified applicants will receive consideration for employment without regard to race, color, religion, national origin, gender, sexual orientation, gender identity, age, physical or mental disability, or protected veteran status. EEOC is the Law/EEO Policy Statement

Drug-Free Company

Pioneer Human Services is a Drug-Free Company Pioneer Human Services is a drug free company. Pioneer’s existing drug-free workplace policy prohibits the use of marijuana, including medical marijuana, and complies with Washington law. As such, this position is subject to drug testing during employment, to include testing for marijuana