Utilization Review Coordinator

Pioneer Human Services; Sedro-Woolley (WA); On-site; USD 38,000 - 47,000; Full time

Benefits offered by this job

Medical

Flexible spending

Dental

Vision

Life, AD&D, Disability

Tuition assistance

Retirement plan

Public transportation discount

EAP

Job summary

Pioneer Human Services in Washington state is seeking a Utilization Review Coordinator to help improve revenue integrity and ensure timely payments. You will critically review guest medical records for completeness, coordinate with clinical teams, and ensure proper authorizations are in place.

The role emphasizes monitoring utilization patterns, appeals processes with payers, and maintaining UR documentation in the EMR. A health-care related degree and relevant experience are valued.

Qualifications

• Associate's degree in health care, business, or related field (or 2 years of experience).
• 2 years of experience working with individuals with behavioral health conditions.
• 2 years of experience in substance use or mental health fields.

Responsibilities

• Reviews treatment plans for documentation, continuity of care, and compliance.
• Reviews client records to determine medical necessity and need for continuing treatment.
• Monitors utilization patterns and notifies leadership of issues.
• Maintains UR documentation in EMR and coordinates with payers.
• Submits appeals for denied authorizations with clinical/demographic data.
• Coordinates with health plans, hospitals, and physicians to ensure coverage.
• Ensures excellent customer service to payers, vendors, and internal customers.
• Maintains access to EMR, payer portals, and required systems.

Skills

Utilization management

Behavioral health experience

Education

Associate's degree in health care / business or related field

Bachelor's degree in health care / business (preferred)

Tools

EMR systems

Payer portals

Quick MAR

Job 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 Coordinator 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 $27.45 and $34.31 hourly, depending on factors such as work location, experience, qualifications, skills, competencies, 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:

Eligible after 30 days of full-time employment (minimum of 30 hours/week):

• Medical
• Flexible spending
• Dental
• Vision

Additional coverage after 60 days:

• Life
• AD&D
• Disability

Other benefits:

• Dependent Daycare Flexible Spending
• Tuition assistance (100% for bachelor's, 50% for graduate programs)
• Retirement plan (3.5% annual compensation contribution, plus 3.5% match for 6% individual contribution)
• Employee recognition programs
• Public transportation discount
• Employee assistance program (EAP)

Join Pioneer and be part of a team that values and invests in you.

What you’ll do
The goal of utilization management is to control costs, improve revenue collection, and ensure data integrity. The Utilization Review Coordinator will critically examine 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:

• Reviews treatment plans to ensure proper documentation, continuity of care, and compliance
• Reviews client records using utilization criteria to ensure medical necessity and determine need for continuing treatment

• Monitors utilization patterns including daily census, no-shows, and AMAs and notifies leadership of potential utilization issues
• 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

• Negotiates length of stay with payers
• Collaborates with clinical team to ensure accuracy of payer information, placement, clinical status, and discharge needs
• Coordinates with health plan organizations, hospitals, doctors, and pharmacists to ensure services are covered and to improve treatment outcomes
• Composes and sends professional communication related to medical records and case coordination
• 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 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

• Associate’s degree in health care, business, or related field or two years of experience in Utilization Management/Medical Administrative Assistant

• 2 year of experience working with individuals with behavioral health conditions
• 2 years of experience working in substance use or mental health fields

Preferably you’ll bring

• Bachelor’s degree or higher in health care, business or related field
• Experience in Medical 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. EEO is the law poster EEO is the law poster supplement

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