Utilization Review Coordinator

Guidelight Health; United States; Remote; USD 27,552 - 41,328; Full time

Benefits offered by this job

Medical, dental, vision insurance

401(k) with company match

$1,500 tuition reimbursement

Job summary

A behavioral healthcare organization is seeking a Utilization Review Specialist to conduct clinical auditing and negotiate authorizations. The ideal candidate has a Bachelor's degree in Social Work or Nursing and 1-2 years of healthcare experience. Responsibilities include conducting live reviews, coordinating with clinical teams, and ensuring compliance with regulations. The position offers a pay range of $20 - $30 USD, along with comprehensive benefits including medical, dental, and professional development opportunities.

Qualifications

• 1-2 years of experience in healthcare in utilization review or clinical care.
• Expert understanding of patient documentation and chart auditing.
• Proficient in applicable software systems.

Responsibilities

• Conduct utilization reviews and negotiate authorizations with payors.
• Coordinate with clinical teams for coverage guidance.
• Document authorization processes in KIPU/Avea.

Skills

Utilization Review

Clinical Auditing

Data Entry

Communication Skills

Analytical Skills

Education

Bachelor's degree in Social Work, Nursing, or related field

Tools

MS Office

KIPU/Avea

Job description

Overview

Guidelight Health is a cutting-edge behavioral healthcare company dedicated to transforming lives through high-quality PHP (Partial Hospitalization Program) and IOP (Intensive Outpatient Program) services. As a newly launched organization, we are on a mission to redefine the behavioral health industry by delivering exceptional care, utilizing state-of-the-art facilities, and prioritizing the well-being of those we serve. At Guidelight Health, we are building a team of passionate, forward-thinking professionals who are eager to be part of this exciting journey to reshape mental health care. Join us in making a lasting impact!

Reports to: SeniorDirector of Revenue Cycle Management

Department/Location: Remote

FLSA Status: Exempt

Travel Requirement: None

Responsibilities

• Utilization Review on Behalf of the Clinics:
  • Prescreen referrals to project/anticipate authorizations. Provide recommendations regarding level of care/services and treatment planning.
  • Conduct live reviews with payors and level of care chart reviews, conceptualizing the clinical presentation and care needs and applying medical necessity guidelines and /or LOCUS to compel authorization.
  • Clinically negotiate authorization outcomes with the payor, collaborating in advance with the primary treating clinicians.
  • Coordinate Peer-to-Peer (P2P) Review preparation and assist with scheduling. Provide guidance and training to clinicians on completing P2P reviews.
  • Establish internal authorization or denial determinations for No Authorization Required (NAR) requests.
  • Establish post denial appeal response recommendations.
  • Obtain portal access to any utilization review portals for an efficient and scalable process.
• Interdepartmental Relations and Communication:
  • Coordinate with the clinical team on requests with clinically weaker presentations.
  • Coordinate all concurrent insurance reviews with clinicians and medical team.
  • Provide guidance on specific interventions or areas on which to focus to result in maximum authorized days.
  • Provide ongoing feedback and recommendations for improvement to meet payor medical necessity guidelines.
  • Attend and participate in daily huddles/weekly rounds as the payor expert to ensure appropriate authorization outcomes and provide ongoing education regarding payor requirements.
  • Communicate with relevant parties at the facility and in RCM about any issues with coverage or denials, facilitating client notifications as needed.
  • Partner with intake, utilization review, and finance for best practices in overarching company goals related to RCM.
  • Timely completion of the Denial Notification process.
• Accurate Data Entry:
  • Document deficiencies for identification on the daily reporting
  • Timely documentation of authorization in KIPU/Avea
  • Upload authorization letters to KIPU/Avea UR module.
• Clinical Auditing:
  • Notify the primary therapist of any missing documentation or delinquent services
  • Review medical records for quality clinical documentation and compliance with licensing, accrediting, and payor requirements
  • Running daily reports to ensure that all information needed for timely review has been entered into the EMR and communicating with the clinic team members to correct or update any missing or incorrect documentation.
• Policy Compliance:
  • Ensuring compliance with legal, regulatory, and policy requirements.
• Process Improvement:
  • Identifying Clinical problems and proposing innovative solutions.
• Additional job duties as assigned.

Qualifications

• Bachelor's degree in Social Work, Nursing, or any related field.
• Clinical or UR experience in PHP or IOP levels of care.
• 1-2 years of experience in the healthcare industry in utilization review or clinical care.
• Expert understanding of patient documentation, chart auditing, and state and federal regulations.
• Proficient in MS Office applications and ability to learn department and job-specific software systems (e.g., applicable practice management and EMR systems).
• Demonstrate organizational skills.
• Demonstrate effective verbal and written communication skills.
• Demonstrate analytical skills when problem-solving.
• Demonstrate high attention to detail and a high degree of accuracy.

Pay Range

$20 - $30 USD

Benefits

• Health & Wellness: Medical, dental, vision, HealthJoy unlimited therapy, UHC wellness program, HSA/FSA options, and pet insurance.
• Time Off: Responsible PTO covering vacation, sick leave, and select federal holidays.
• 401(k): With company match.
• Professional Development: $1,500 tuition reimbursement for ongoing education or CEUs, and opportunities for cross-licensure when applicable.