Utilization Review Coordinator

Community Health Systems; Franklin (TN); On-site; USD 52,000 - 76,000; Full time

Job summary

Community Health Systems seeks an Utilization Review Coordinator to manage authorizations for hospital admissions and extended stays. The role collaborates with payers and clinical staff to optimize patient outcomes and reduce denials.

Responsibilities include documenting authorization activities, monitoring KPIs, and serving as a liaison to ensure timely communications with payers and hospital teams.

Qualifications

• Strong knowledge of utilization management principles, payer requirements, and healthcare regulations.
• Proficiency in case management systems and technology resources for authorization tracking and documentation.

Responsibilities

• Submits initial assessments, continued stay reviews, and payer documentation, ensuring compliance with policies, regulations, and payer requirements to establish medical necessity.
• Communicates with commercial payers to provide concise and accurate information to secure timely authorizations and reduce potential denials, utilizing input from the Utilization Review Clinical Specialist.
• Monitors and updates case management software with documentation of escalations, avoidable days, authorization numbers, denials, and payer interactions to ensure accurate records.
• Coordinates Peer-to-Peer discussions for unresolved concurrent denials, ensuring the process aligns with hospital, corporate, and payer requirements. Documents outcomes in case management systems.
• Reviews and closes out cases after patient discharge, ensuring all required documentation is complete and understandable for billing and future audits.

Skills

Utilization management

Communication

Organization

Problem solving

Attention to detail

Education

HS Diploma or GED

Bachelor's degree preferred

Tools

Case management system

Job description

Job Summary

The Utilization Review Coordinator ensures efficient and effective management of utilization review processes, including denials and appeals activities. This role collaborates with payers, hospital staff, and clinical specialists to secure timely authorizations for hospital admissions and extended stays. The Utilization Review Coordinator monitors and documents all authorization activities, assists with process improvement initiatives, and serves as a key liaison to reduce denials and optimize patient outcomes.

Essential Functions

• Submits initial assessments, continued stay reviews, and payer-requested documentation, ensuring compliance with policies, regulations, and payer requirements to establish medical necessity.

• Communicates with commercial payers to provide concise and accurate information to secure timely authorizations and reduce potential denials, utilizing input from the Utilization Review Clinical Specialist.

• Monitors and updates case management software with documentation of escalations, avoidable days, authorization numbers, denials, and payer interactions to ensure accurate records.

• Coordinates Peer-to-Peer discussions for unresolved concurrent denials, ensuring the process aligns with hospital, corporate, and payer requirements. Documents outcomes in case management systems.

• Reviews and closes out cases after patient discharge, ensuring all required documentation is complete and understandable for billing and future audits. Places cases on hold as necessary to resolve pending authorizations or reviews.

• Maintains performance metrics aligned with Key Performance Indicators (KPIs) for the Utilization Review Service Line.

• Serves as a key contact for facility and payer representatives, fostering effective communication and collaboration to resolve issues promptly.

• Participates in training initiatives within the department, supporting onboarding and skill development for team members.

• Responds promptly to phone calls, faxes, and insurance portal requests, providing high standards of customer service and satisfaction.

• Escalates issues to the manager as appropriate and provides recommendations for improving operational efficiency and outcomes.

• Ensures accurate and timely communication of hospital stay authorizations, denials, and delays to all relevant stakeholders.

• Performs other duties as assigned.

• Maintains regular and reliable attendance.

• Complies with all policies and standards.

Qualifications

• H.S. Diploma or GED required

• Bachelor's Degree preferred

• 0-2 years of work experience in utilization review, hospital admissions or registration required

• 1-3 years of work experience in an office, processing center, or similar environment preferred

Knowledge, Skills and Abilities

• Strong knowledge of utilization management principles, payer requirements, and healthcare regulations.

• Proficiency in case management systems and technology resources for authorization tracking and documentation.

• Excellent communication and interpersonal skills to interact effectively with payers, clinicians, and administrative staff.

• Critical thinking and problem-solving skills to analyze and resolve authorization and denial issues.

• Strong organizational skills to manage multiple priorities and meet deadlines.

• Attention to detail for accurate documentation and process adherence.

• Ability to train and support team members, fostering a collaborative and productive environment.

Equal Employment Opportunity

This organization does not discriminate in any way to deprive any person of employment opportunities or otherwise adversely affect the status of any employee because of race, color, religion, sex, sexual orientation, genetic information, gender identity, national origin, age, disability, citizenship, veteran status, or military or uniformed services, in accordance with all applicable governmental laws and regulations. In addition, the facility complies with all applicable federal, state and local laws governing nondiscrimination in employment. This applies to all terms and conditions of employment including, but not limited to: hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training. If you are an applicant with a mental or physical disability who needs a reasonable accommodation for any part of the application or hiring process, contact the director of Human Resources at the facility to which you are seeking employment; Simply go to http://www.chs.net/serving-communities/locations/ to obtain the main telephone number of the facility and ask for Human Resources.