Utilization Review Coordinator

Health Plans, Inc.; United States; On-site; USD 75,000 - 95,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

401(k) plan

Paid time off

Job summary

Health Plans, Inc. is seeking a UM Review Coordinator to review clinical information for medical necessity, determine appropriate level of care, and length of stay using standardized criteria.

The role includes gathering information, coordinating with Peer Reviewers, and managing utilization with timely documentation. The ideal candidate holds an RN license in MA/ME/NH or residency state, with at least three years in acute care and proficiency in Microsoft Office.

Qualifications

• A minimum of three years of experience in an acute care clinical setting.
• Active, current and unrestricted professional licensure as an RN in Massachusetts, Maine, New Hampshire or state of residency.
• Proficient in Microsoft Office, including Word, Excel, Outlook and PowerPoint

Responsibilities

• Gather relevant clinical information from appropriate health care providers.
• Confirm medical necessity for procedures based on standardized criteria; refer non-confirmable cases to Peer Reviewer.
• Conduct utilization management of appropriate level of care and length of stay.
• Consult with Peer Reviewers when peer input is needed.
• Provide timely case screening and referrals to Case Management or other programs.
• Ensure timely follow up on utilization management issues and inquiries.
• Collaborate with health care providers to identify discharge needs and facilitate timely discharge.
• Communicate with providers regarding the Utilization Management process.
• Ensure case documentation follows policy and procedures.
• Demonstrate ongoing professional growth with Manager guidance.
• Maintain quality audit scores and manage caseload efficiently.
• Adhere to HIPAA policies and procedures

Skills

Clinical review

RN licensure

Microsoft Office

Communication skills

Education

RN licensure (Massachusetts/Maine/New Hampshire)

Tools

Microsoft Office (Word, Excel, Outlook, PowerPoint)

Job description

Do you envision working for a company that has the expertise of a long-standing industry leader, but the spirit of an entrepreneur? Does the thought of making a real impact motivate and energize you? If so, HPI is the place for you. Join a team that values integrity, flexibility, loyalty, compassion and dedication—we can’t wait to meet you.

What we do

HPI is unique. A respected industry leader that’s been serving customers for over 44 years, we’re known for our innovation and adaptability. Our experience has given us our expertise, but our forward-thinking, entrepreneurial spirit has given us our strong reputation. As a third-party administrator, we offer a suite of health and benefit solutions to employers. By joining HPI, you’ll contribute to ideas that make a real difference for employers and employees nationwide. There isn’t a challenge we won’t accept and we’re looking for people who have a passion to take it on. Not just a job—a mission.

Our commitment extends beyond our clients to our own employees. We foster a supportive and inclusive work environment where innovation thrives. By investing in our team’s growth and well-being, we ensure they are equipped to provide exceptional service.

What you’ll do

The UM Review Coordinator performs review of clinical information submitted to determine medical necessity, appropriate level of care and length of stay, based on standardized clinical criteria. The UM Review Coordinator renders positive determinations for cases that meet the criteria and refers all other cases for physician peer review (“Peer Reviewer”).

In this role, you’ll also:

• Gather relevant clinical information from appropriate health care providers
• Confirm medical necessity for selected procedures and services based on application of standardized clinical criteria to clinical information submitted; if a positive determination cannot be made based on the criteria, refer case to Peer Reviewer
• Conduct utilization management of appropriate level of care and length of stay using standardized clinical criteria
• Consult with Peer Reviewers when a positive determination cannot be made based on the standardized criteria or peer consult is needed to determine appropriateness of care beyond the standardized criteria
• Provide timely case screening to identify case management needs and generate appropriate referrals to Case Management or other appropriate clinical programs;
• Ensure timely follow up on outstanding utilization management issues and inquiries
• Collaborate with health care providers to identify discharge needs in order to facilitate timely discharge to an appropriate level of care, with referral to Case Management as appropriate
• Communicate with providers and other health care professionals regarding the Utilization Management process
• Ensure case documentation follows policy and procedure
• Proactively manage professional growth by collaborating with Manager to identify as appropriate
• Demonstrate consistent and appropriate application of standardized criteria for purposes of interrater reliability
• Maintain satisfactory quality audit scores
• Manage work time and caseload efficiently
• Adherence to HIPAA policies and procedures

What you bring

• A minimum of three years of experience in an acute care clinical setting.
• Active, current and unrestricted professional licensure as an RN (Registered Nurse) in Massachusetts, Maine, New Hampshire or state of residency
• Proficient in Microsoft Office, including Word, Excel, Outlook and PowerPoint

Why choose us?

• We’re a people-first company and value giving back to our community. Ask us about our volunteer opportunities.
• Our space is a reflection of who we are—innovative, open and collaborative.
• We think feeling your best is an important factor in producing great work, so we embrace a “smart casual” dress code and work at ergonomic desks.
• Need to reenergize? When at our Westborough headquarters, take a break to chat in the onsite café, go for a walk on one of the beautiful trails in our office park, or get in a quick workout at one of the campus gyms.

Our Benefits Package

We care about you and believe the greatest gift you can give yourself, your family, and the world is a healthy you! We offer a comprehensive and competitive benefits package to help you lead a happy, healthy life, including:

• Medical, Dental and Vision and Prescription Drug Coverage
• Fitness Reimbursement Benefit
• Employee Assistance Program
• Flexible Spending Account & Health Savings Account
• 401(k) and Quarterly Bonuses
• Generous Paid-Time Off & Volunteering Opportunities
• Educational Assistance & Professional Development Opportunities

So, think you want to join the HPI team? We hope to hear from you!

You can read more about us at hpitpa.com/about-us/careers/