Utilization Review (UR) / Utilization Management (UM) Coordinator

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

Responsibilities

Utilization Review (UR) / Utilization Management (UM) Coordinator Opportunity

Turning Point Care Center provides comprehensive behavioral health care for adults experiencing chemical dependency, acute psychiatric disorders, or a dual diagnosis. For more than 40 years, our team has provided a place of healing and hope through a full continuum of inpatient and outpatient care, with programs tailored to meet each patient’s unique needs.

Nestled in a serene, rural setting in Moultrie, Georgia, Turning Point offers a calming, secure environment where patients can focus on recovery and build a foundation for lifelong wellness. Our commitment to quality care is grounded in the belief that healthy communities begin with healthy individuals and strong connections to family, friends, and peers.

Centrally located in South Georgia, our facility is just 30 minutes from I-75, 1.5 hours north of Tallahassee, 3 hours south of Atlanta, and 2.5 hours west of Jacksonville. Turning Point offers a rewarding opportunity to build a career while making a meaningful difference in the lives of those we serve.

Visit the site virtually: turningpointcare.com

The Utilization Review / Utilization Management Coordinator oversees utilization management functions to monitor the appropriateness and continuity of patient care while optimizing reimbursement. This position conducts clinical reviews, monitors patient records and treatment plans, communicates with insurance providers and treatment team members, and ensures compliance with applicable requirements.

Job Duties/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

Benefit & Rewards Highlights

• Challenging and rewarding work environment
• Competitive compensation & generous Paid Time Off
• Excellent Medical, Dental, Vision and Prescription Drug Plans
• 401(K) with company match and discounted stock plan
• SoFi Student Loan Refinancing Program
• Tuition saving to continue your nursing education with Chamberlain University
• Career development opportunities within UHS and its 300+ Subsidiaries!
• Pet Insurance
• More information is available on our Benefits Guest Website: uhsguest.com

About Universal Health Services

Headquartered in King of Prussia, PA, Universal Health Services, Inc. (NYSE: UHS) is one of the nation’s largest and most respected providers of hospital and healthcare services. Since our founding in 1979, UHS has grown steadily into a premier Fortune 500 corporation perennially recognized by multiple esteemed national rating entities. Through its subsidiaries, UHS operates inpatient acute care facilities, inpatient behavioral health facilities, outpatient and other facilities, nationwide virtual behavioral health services, an insurance offering, a physician network and various related services with physical locations in the U.S., Puerto Rico, Ireland and United Kingdom. www.uhs.com

Qualifications

Requirements

• 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, situa tional evalua tions, and crisis intervention preferred

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.