Utilization Review Coordinator: Impactful Healthcare Role

Universal Health Services, Inc.; Moultrie (GA); On-site; USD 65,000 - 90,000; Full time

Job summary

Turning Point Care Center in Moultrie, GA, seeks a Utilization Review/Utilization Management Coordinator to monitor patient care continuity and optimize reimbursement. The role conducts clinical reviews, monitors records, and ensures compliance within inpatient and outpatient programs.

The ideal candidate holds a state nursing or counseling license and has at least 3 years’ UR/medical terminology experience, with knowledge of ASAM/DSM-5 criteria and diverse insurance plans.

Qualifications

• Licensed through state board for Nursing or Counseling/Therapy.
• RN, LMSW, LAPC, or LAMFT required; BSN, MSN, LCSW, LPC, or LMFT preferred.
• Three years’ experience in chart analysis, utilization review, medical/clinical terminology, and acuity of illness.
• Knowledge and understanding of a variety of insurances including Traditional Medicare, Medicare Advantage Plans, and Commercial Plans.
• Knowledge and experience with chemical dependency and mental health programs, situational evaluations, and crisis intervention preferred.

Responsibilities

• Conduct concurrent and extended-stay reviews using ASAM criteria and DSM-5 guidelines to determine medical necessity, appropriateness of care, continued stay, and discharge criteria.
• Collaborate with Admissions, Clinical Staff, Nursing, Medical Records, Business Office, and providers to address insurance issues and communicate patient information and benefits.
• Review patient records, treatment plans, and clinical status; communicate pertinent third-party payor requirements and acuity concerns to physicians and the treatment team.
• Perform clinical reviews with insurance case managers by telephone and electronically while maintaining positive working relationships with third-party payors.
• Maintain accurate and timely documentation in MIDAS and other Utilization Management records; run and interpret reports as needed.
• Prepare and submit timely appeals to third-party payors, working with the Business Office and treatment team to gather supporting documentation.
• Attend treatment team and AR/Denials meetings and maintain records in accordance with applicable policies, regulatory requirements, and accreditation standards.

Skills

Chart analysis

Utilization review

Medical terminology

Acuity of illness

Insurance knowledge

Chemical dependency knowledge

Crisis intervention

Education

RN or LMSW or LAPC or LAMFT required

BSN or MSN or LCSW or LPC or LMFT preferred

Tools

MIDAS

Job description

Turning Point Care Center in Moultrie, GA, seeks a Utilization Review/Utilization Management Coordinator to monitor patient care continuity and optimize reimbursement. The role conducts clinical reviews, monitors records, and ensures compliance within inpatient and outpatient programs.

The ideal candidate holds a state nursing or counseling license and has at least 3 years’ UR/medical terminology experience, with knowledge of ASAM/DSM-5 criteria and diverse insurance plans.