Utilization Review Coordinator

Bradford Health Services; United States; On-site; USD 55,000 - 75,000; Full time

Benefits offered by this job

Medical coverage

Retirement benefits

Paid time off (PTO)

Employee assistance program

Telehealth options

Job summary

Bradford Health Services is seeking a Utilization Review Coordinator to join our clinical team. The role ensures that patient services are medically necessary, efficient, and compliant with regulatory standards.

You will review patient records, treatment plans, and data to determine the appropriateness of care and resource use, collaborating with providers, insurers, and case managers to facilitate timely approvals.

Qualifications

• Bachelor’s degree in a healthcare or related field is required.
• 2+ years in utilization review, case management, or clinical healthcare roles.
• Strong knowledge of medical terminology, clinical procedures, and healthcare regulations.
• Familiarity with insurance authorization processes and healthcare reimbursement models.
• Excellent analytical, communication, and organizational skills are expected.

Responsibilities

• Review and analyze medical records, treatment plans, and clinical documentation to assess necessity and appropriateness of services.
• Coordinate with healthcare providers, insurance representatives, and case managers to obtain information and clarify treatment details.
• Make informed decisions regarding authorization, continuation, modification, or denial of services based on guidelines and requirements.
• Maintain detailed records of utilization review activities in compliance with policies and legal standards.
• Stay current with evolving healthcare regulations, payer policies, and clinical best practices.

Skills

Analytical skills

Communication

Organizational skills

Healthcare regulations

Insurance authorization

Education

Bachelor’s degree in healthcare or related field

Tools

EHR systems

Utilization management software

Job description

Red Oak Recovery Center is a clinician-run treatment program with campuses established to serve the needs of our clients. Our Red Oak campuses offer a unique blend of clinical rehabilitation, 12 step addiction recovery, proven addiction therapy services, family counseling, and experiential and adventure therapy for men. The Willows at Red Oak offers a sanctuary for women to focus on healing and help prepare them for fulfilling, post-treatment lives.

We are seeking a Utilization Review Coordinator to add to our dynamic team. The Utilization Review Coordinator plays a critical role in ensuring that healthcare services provided to patients are medically necessary, efficient, and compliant with regulatory standards. This position involves thorough evaluation of patient records, treatment plans, and clinical data to determine the appropriateness of care and resource utilization. This position collaborates closely with healthcare providers, insurance companies, and case managers to facilitate timely approvals and optimize patient outcomes. By applying clinical knowledge and regulatory guidelines, the role helps control healthcare costs while maintaining high-quality patient care. Ultimately, the Utilization Review Coordinator contributes to the integrity and sustainability of healthcare delivery systems across the United States.

Responsibilities

• Review and analyze medical records, treatment plans, and clinical documentation to assess the necessity and appropriateness of healthcare services
• Coordinate with healthcare providers, insurance representatives, and case managers to obtain additional information and clarify treatment details
• Make informed decisions regarding authorization, continuation, modification, or denial of services based on clinical guidelines and regulatory requirements
• Maintain accurate and detailed records of utilization review activities, decisions, and communications in compliance with organizational policies and legal standards
• Stay current with evolving healthcare regulations, payer policies, and clinical best practices to ensure consistent and compliant review processes

Minimum Qualifications

• Bachelor’s degree in a healthcare or related field
• At least 2 years of experience in utilization review, case management, or clinical healthcare roles
• Strong knowledge of medical terminology, clinical procedures, and healthcare regulations
• Familiarity with insurance authorization processes and healthcare reimbursement models
• Excellent analytical, communication, and organizational skills

Preferred Qualifications

• Experience with electronic health records (EHR) systems and utilization management software
• Certification in Utilization Review (e.g., Certified Professional in Utilization Review or Certified Case Manager)
• Prior experience working with managed care organizations or insurance companies
• Advanced knowledge of Medicare, Medicaid, and other payer-specific guidelines

We’re officially a Great Place to Work! We’ve always believed that supporting our team is just as important as supporting our patients. Now, we’re proud to share that we’ve earned Great Place to Work Certification - based entirely on feedback from our own employees. Read more here: https://ow.ly/YQ1C50WuRH1

This certification reflects the culture we’ve worked hard to build - one rooted in trust, inclusion, and purpose-driven leadership.

At Bradford Health Services, we are committed to providing exceptional care to our patients while fostering a supportive and rewarding workplace for our employees. We believe that taking care of our team allows them to take better care of others, which is why we offer a comprehensive benefits package designed to support their well-being.

• Medical Coverage – Three new BCBSAL medical plans with better rates, improved co-pays, and enhanced prescription benefits.
• Expanded Coverage – Options for domestic partners and a wider network of in-network providers.
• Mental Health Support – Improved access to services and a new Employee Assistance Program (EAP) featuring digital wellness tools like Cognitive Behavioral Therapy (CBT) modules and wellness coaching.
• Voluntary Coverages – Pet insurance, home and auto insurance, family legal services, and more.
• Student Loan Repayment – Available for nurses and therapists.
• Retirement Benefits – 401(k) plan through Voya to help employees plan for the future.
• Generous PTO – A robust paid time off policy to support work-life balance.
• Voluntary Benefits for Part-Time Employees – Dental, vision, life, accident insurance, and telehealth options for those working 20 hours or more per week.

https://info.flclearinghouse.com