Utilization Review Coordinator

JOB SUMMARY

Manages the administrative components of utilization review for all levels of care and all payers. Serves as the organization's central point of accountability for authorization tracking, assuring that prior authorizations, continued stay reviews, requests for information, reconsiderations, and retrospective reviews are complete and submitted within required timeframes. This is a non-clinical position: the UR Coordinator does not determine medical necessity or author clinical content, but requests clinical documentation from clinical staff according to the department's provider priority list, assembles and reviews submission packets for completeness, submits them, and tracks each authorization from admission through discharge and billing. Partners with the business office on authorization-related denials and unauthorized days, and with clinical leadership on clinical input and appeals. Assures adherence to Montana Medicaid and BHDD utilization management requirements, payer-specific requirements, and federal regulations including HIPAA and 42 CFR Part 2. Positively represents the organization and promotes Rimrock's Mission to the community.

ESSENTIAL FUNCTIONS

• Maintains the UR tracker as the single record of every authorization across Medicaid and commercial payers, including authorized dates, units, next deadlines, assigned clinical staff, status, and outcomes.
• Monitors authorization end dates and calendars all required deadlines, including continued stay submission windows, request for information responses, peer-to-peer and desk review requests, and retrospective review windows.
• Verifies payer eligibility and authorization requirements at admission in partnership with admissions and billing.
• Requests clinical documentation from clinical staff with clear due dates, assigning each request according to the department's provider priority list, which ranks available clinical staff by credential level appropriate to the request and current availability.
• Follows up on outstanding clinical documentation requests; reassigns to the next available provider on the priority list and escalates unresolved requests to the Assistant Controller and the Director of Clinical Services.
• Schedules peer-to-peer reviews between payer reviewers and the appropriate Rimrock clinician or physician.
• Assembles authorization and continued stay packets from the electronic health record and reviews them for completeness against payer requirements; does not create clinical content or determine medical necessity.
• Submits authorization requests through payer portals, including the Montana Medicaid utilization review contractor portal, and by fax and telephone within required timeframes.
• Assures that documentation supporting auto-authorized services is submitted within the timeframe required by the payer.
• Logs determinations, requests for information, and denials; routes requests for information to the author of the original documentation and submits responses within required timeframes.
• Prepares and files written requests for reconsideration, including peer-to-peer and desk reviews, and tracks each to resolution.
• At discharge, reconciles final authorized dates with actual dates of service, closes the case with the payer or review contractor, and notifies billing of any unauthorized days before claims are submitted.
• Works authorization-related denials with the accounts receivable team, identifies root causes, and recommends process corrections.
• Submits retrospective review requests when patients become Medicaid eligible after admission.
• Maintains written payer requirements, contacts, templates, and desk procedures; cross-trains a designated backup.
• Monitors BHDD Medicaid provider manual updates and payer utilization review policy changes and communicates changes to business office and clinical staff.
• Assures utilization review data required for quality improvement, state, and payer reporting is accurate and submitted on schedule.
• Other duties as assigned.

CUSTOMER SERVICE RESPONSIBILITIES

• Provides timely and thorough follow-up with internal and external customers.
• Obtains feedback from patients regarding their perceptions of the service provided to them and utilizes this information to improve service delivery.
• Serves on committees or process improvement teams to assist in improving quality/customer satisfaction, as assigned.
• Models professionalism by addressing others with appropriate actions, appearance and communication.

QUALITY IMPROVEMENT RESPONSIBILITIES

• Prepares and presents monthly utilization review performance measures, including authorized days lost to late or missed submissions, on-time submission rate, request for information turnaround, technical denials by cause, appeal outcomes, and auto-authorization quality scores.
• Assures that information is collected, organized, reported and used to improve the quality of systems and services.
• Reviews denial and unauthorized-day trends with the Assistant Controller and the Director of Clinical Services and recommends corrective action.
• Self-audits auto-authorization submissions against payer quality criteria and escalates any change in the organization's rating.
• Assures the UR tracker is current and reviewed weekly so that no authorization, request for information, or appeal deadline is missed.
• Ensures compliance, regulatory and quality management standards are met.
• Serves on committees or process improvement teams to assist in improving quality/customer satisfaction, as assigned.
• Performs self-quality monitoring in order to develop and execute plans to meet established goals.

ORGANIZATIONAL COMPETENCIES

• Accountability – Takes ownership for resolving problems, reaching goals, and serving patients, team, and organization. Accepts responsibility for own behavior. Assures that resources are allocated in accordance with the priorities of the strategic plan. Performs self-quality monitoring in order to develop and execute plans to meet established goals.
• Time Management – Maximizes the use of time and resources and effectively prioritizes tasks. Completes paperwork, evaluations, and other required documentation accurately and timely.
• Teamwork – Works cooperatively and capably with a wide variety of people. Actively promotes teamwork and information sharing within and across departments. Works in a spirit of teamwork and trust and maintains professional boundaries in working with others.
• Flexibility – Adapts rapidly to changing work demands and priorities.
• Confidentiality – Complies with all HIPAA and 42 C.F.R. Part 2 regulations relating to privacy, security, and confidentiality. Safeguards confidential information of patients, employees, and business operations
• Safety – Knows and understands emergency procedures and completes incident reports within 24 hours of event with detailed information.
• Communication – Consistently uses positive communication skills to promote effective interpersonal relationships. Provides timely and thorough follow-up with internal and external customers. Models professionalism by addressing others with appropriate actions, appearance, and communication. Models and promotes effective written and verbal communication.
• Customer Service – Supports the organization’s customer service initiative. Strives for service excellence by seeking challenges and turning them into opportunities. Anticipates and meets needs of patients while maintaining appropriate boundaries. Displays a friendly, helpful, and approachable demeanor. Obtains feedback from patients regarding their perceptions of the service provided to them and utilizes this information to improve service delivery.
• Respect – Establishes compassionate and supportive rapport with patients. Communicates tactfully and respectfully with patients, coworkers, and others.
• Quality Improvement – Assures that information is collected, organized, reported and used to improve the quality of systems and services. Recognizes and appropriately reports to supervisor areas within scope of responsibility that fall outside the quality parameters. Serves on committees or process improvement teams to assist in improving quality/customer satisfaction, as assigned.

EDUCATION/TRAINING

High school diploma or equivalent required; associate degree in health information management, medical billing, business, or a related field preferred. Minimum of two years' experience in healthcare billing, prior authorizations, insurance verification, medical records, or a medical office setting. Experience in behavioral health or substance use disorder treatment, and familiarity with Montana Medicaid, ASAM levels of care, and the BHDD Medicaid Services Provider Manual preferred. Certification such as Certified Professional Biller (CPB), Certified Revenue Cycle Specialist (CRCS), or Registered Health Information Technician (RHIT) preferred.

SKILLS

Organization, deadline and caseload management, written and verbal communication, attention to detail, records management, and problem-solving skills. Working knowledge of medical terminology and payer authorization processes. Ability to work independently, prioritize competing deadlines, and follow up professionally with clinical staff and payers. Computer skills and proficiency with electronic health record systems, payer portals, and Microsoft software including Word, Excel and Outlook.

PHYSICAL DEMANDS

Work is indoors in an office environment with moderate noise. Intermittent physical effort involving lifting of up to 25 pounds, walking and stooping is required. A typical workday involves sitting, frequent use of a keyboard, reaching with hands and arms, and talking and hearing, approximately 70% of the time. Approximately 30% or less of the time is spent standing. Normal vision abilities required, including close vision and ability to adjust focus.

WORK ENVIRONMENT/JOB LOCATIONS

Involves everyday risk or discomfort requiring normal safety precautions in an office setting, meeting room and patient care areas. Work may involve mental and emotional stress. Some driving required.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of responsibilities, duties and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed.