Utilization Review Coordinator

Job Summary

The role of the Utilization Review Coordinator is responsible for managing all utilization related activities for behavioral health services to ensure high-quality, cost-effective care. This role works closely with the treatment team, insurance companies, revenue cycle management, and other stakeholders to ensure programming meets payor requirements and documentation demonstrates medical necessity, aligning with evidence-based practices.

Roles & Responsibilities

· Expert in payor expectations and requirements: Through collaborative conversations and consultations, proactively support the clinical team in care planning and in creating documentation that demonstrates medical to ensure authorization of necessary care.

· Member of the Treatment Team: Interactively participates in scheduled meetings and ad-hoc communication to facilitate the clinical team in care planning and gaining authorization for the appropriate length of stay at the appropriate level of care.  

· Manages all Authorization Activities: Submit required forms, documentation, and information timely to achieve authorization and coordinate peer-to-peer activities. Records authorization outcomes as necessary to support billing and collections.

· Oversight of No Authorization Required care: Evaluates medical necessity based on documentation review at admission and at prescribed intervals thereafter to provide an internal authorization.

· Maintain accurate records: Ensure that all utilization review documentation is accurate, adequately detailed, and up-to-date. Ensure accuracy and availability of UR Dashboard.

· Manages denials and appeals to resolution: Manages response to appeals and tracking outcomes, communicating to revenue cycle management on the status and recommendations for next steps.

· Optimization of documentation to support authorization: Provides feedback and recommendations on processes, templates, tools, and quality of documentation.

· Ensures Business Continuity for Utilization related activities: By creating written processes (UR Manual), recording UR activities with adequate detail,  and ensuring necessary access to documents, tools, and portal, coverage will be ensured for planned and unplanned absences.

· Responds to or coordinates with other teams regarding requests for medical records for individual clients or payor audits.

· Provides training and feedback to staff and leadership regarding timeliness or quality concerns regarding documentation which potentially impacts authorization outcomes.

· Point of contact for clients and family for questions regarding authorizations or denials.

· Utilizes electronic systems, payor websites, and live calls if needed for re-verification of other primary payor or upcoming term dates at admission and at least every 30 days thereafter.

· Solves complex problems and takes a new perspective on existing solutions in support of Sanford Behavioral Health goals.

· Perform reviews/audits, analyze audit results and reports finding to promote and improve processes.

· Participate in quality improvement activities and will ensure appropriate tracking/reporting of utilization data across the organization.

· Reports over/under utilization and clinical criteria concerns to Clinical Director.

· Increases Sanford’s capacity to evaluate and improve the effectiveness of their practices, partnerships, programs, use of resources, and the impact the systems’ improvements had on the organizations.

· Adheres to established Code of Ethics, Standards of Practice, and employee handbook.

Qualifications and Education Requirements

· Minimum Bachelor level in behavioral health or nursing.

· Master’s degree preferred.

· Two (2) years’ experience in the areas of behavioral health utilization review or client care.

· Two (2) years’ experience in a behavioral health inpatient setting, preferred.

Knowledge/Skills/Abilities

· Familiarity with healthcare regulations, such as HIPAA and accreditation standards.

· Understanding of medical terminology, including diagnoses, treatments, and medications.

· Knowledge of behavioral health conditions, treatments, and services.

· Understanding of insurance coverage and reimbursement processes.

· Familiarity with evidence-based practices and treatment guidelines.

· Ability to analyze complex data and make informed decisions.

· Strong verbal and written communication skills, with ability to interact with healthcare providers, clients, and insurance companies.

· Ability to identify and resolve problems in a timely and effective manner.

· Strong interpersonal skills, with ability to build relationships with healthcare providers, clients, and insurance companies.

· Ability to think critically and make informed decisions.

· Ability to pay close attention to detail and ensure accuracy in work.

· Ability to organize and prioritize tasks, with ability to manage multiple projects simultaneously.

· Ability to adapt to changing circumstances and priorities.

· Ability to maintain confidentiality and handle sensitive information.

· Familiarity with EHR systems and ability to navigate and utilize them effectively.

· Familiarity with utilization review software/portals and ability to utilize it effectively.

· Proficiency in Microsoft Office, including Word, Excel, and Outlook.

· Ability to provide excellent customer service and interact with clients, families, and other  healthcare providers in a compassionate and  professional manner.

· Ability to work effectively as part of a team with the ability to collaborate and communicate with colleagues.

· Ability to adapt to changing circumstances and priorities, with ability to be flexible and adjust to new situations.

· Ability to prioritize tasks and mange time effectively, with ability to meet deadlines and achieve goals.

· Ability to stay-up-to-date with changing regulations, guidelines, and best practices in utilization review and behavioral health.

· Expertise in the dynamics of addiction and psychiatric conditions.

· Expertise in reviewing regulations for organizations regarding substance use disorder and/or mental health treatment.

· Skilled in conflict resolution.

· Ability to work within a team setting and create an environment where all are valued and work together cohesively.

· Demonstrates professional behavior reflective of Sanford’s Mission Statement, Philosophy, and Values.

· Must be able to relate well to all kinds of people both inside and outside the organization; builds appropriate rapport; builds constructive and effective relationships; uses diplomacy and tact; can diffuse even high-tension situations comfortably.

· Must possess positive attitude to enhance a cooperative and energetic work environment.