Psychiatric Utilization Review Coordinator

WE ARE INSIGHT:

At Insight Hospital and Medical Center- Chicago, we believe there is a better way to provide quality healthcare while achieving health equity. Our Chicago location looks forward to working closely with our neighbors and residents, to build a full-service community hospital in the Bronzeville area of Chicago; creating a comprehensive plan to increase services and meet community needs. With a growing team that is dedicated to delivering world-class service to everyone we meet, it is our mission to deliver the most compassionate, loving, expert, and impactful care in the world to our patients. Be a part of the Insight Chicago team that provides PATIENT CARE SECOND TO NONE! If you would like to be a part of our future team, please apply now!

Position Summary

The Psychiatric Utilization Review (UR) Coordinator is responsible for conducting concurrent reviews for psychiatric patients to ensure medical necessity and continued stay appropriateness. This role serves as a liaison between clinical teams and third-party payers, providing real-time information on authorization status, last covered days, and upcoming review deadlines. The UR Coordinator ensures timely response to calls and faxes, accurate documentation in required systems, and proper escalation of denials to the appeals team.

These duties are to be performed in a highly confidential manner, in accordance with the mission, values and behaviors of Insight Hospital and Medical Center. Employees are further expected to provide a high quality of care, service, and kindness toward all patients, staff, physicians, volunteers and guests.

Key Responsibilities

Utilization Review & Concurrent Reviews

• Conducts concurrent reviews for all active psychiatric patients to determine continued stay medical necessity
• Completes continued stay reviews within required timeframes based on payer requirements and internal deadlines
• Assesses clinical documentation to support ongoing authorization
• Communicates review outcomes and next steps to treatment teams as appropriate
  
  
  

Payer Communication & Authorization Tracking

• Initiates and maintains contact with insurance payers to obtain and verify continued stay authorization
• Documents all payer communications and authorization decisions in appropriate systems.
• Tracks active patient authorizations, last covered days, and next review due dates
• Provides updated authorization information to clinical teams during rounds and as needed
  
  
  

Rounds Participation

• Attends and actively participates in daily or weekly clinical rounds
• Provides real-time updates on each patient's authorization status, including:
• Last covered day
• Next review due date
• Any pending payer actions or concerns
• Notes any changes in patient status that may impact length of stay or authorization
  
  
  

Denials Management

• Receives and reviews denial notices from payers
• Provides denial letters and supporting documentation to the Appeals Team or UR Supervisor for further action
• Updates supervisor on denial particulars as directed
• Tracks denial patterns and reports trends to supervisor
  
  
  

Time-Sensitive Communication

• Monitors and responds to incoming calls from payers, providers, and internal departments in a timely manner
• Processes incoming faxes related to authorizations, denials, and clinical documentation throughout the day
• Ensures no voicemail or fax goes unaddressed beyond 24 hours
• Escalates urgent or complex issues to supervisor immediately
  
  
  

Documentation & Data Management

• Maintains timely and accurate records of all utilization review activities
• Documents all reviews and actions in required systems
• Ensures that notes are complete, clear, and reflect actions taken and what is pending by the end of the shift
• Assists with data collection as requested by supervisor
  
  
  

Support & Collaboration

• Collaborates with Pre-Cert Specialists to ensure smooth handoff between initial certification and concurrent review
• Communicates authorization updates to crisis team, social workers, and providers
• Participates in team meetings and contributes to process improvement discussions
  
  
  

Compliance & Regulatory Knowledge

• Maintains knowledge of medical necessity criteria for psychiatric continued stay reviews
• Understands requirements for Medicare, Medicaid, managed care, and commercial insurance coverage
• Ensures compliance with HIPAA regulations and maintains confidentiality of patient information
• Demonstrates knowledge of inpatient psychiatric treatment and documentation requirements
  
  
  

Qualifications

Education Requirements

• Bachelor's degree in healthcare administration, Psychology, Social Work, or related field; RN preferred
• Relevant experience may be considered in lieu of degree
  
  
  

Experience

• Minimum 1-2 years of experience in utilization review, healthcare administration, or related role required
• Experience working with psychiatric or behavioral health populations strongly preferred
• Familiarity with Medicare, Medicaid, and commercial insurance requirements preferred
• Experience with InterQual/MCG criteria preferred
  
  
  

Knowledge, Skills & Abilities

Knowledge

• Working knowledge of medical necessity criteria for psychiatric continued stays
• Understanding of insurance authorization processes and terminology
• Familiarity with psychiatric diagnoses, DSM-5, and levels of care
• Knowledge of HIPAA and confidentiality requirements
  
  
  

Skills

• Strong organizational skills and attention to detail
• Excellent verbal and written communication skills for interacting with payers and clinical teams
• Ability to prioritize multiple tasks and respond to time-sensitive requests
• Proficiency with electronic medical records (Cerner preferred) and Microsoft Office (Outlook, Excel, Word)
• Critical thinking and problem-solving abilities
• Ability to track and trend denial patterns
  
  
  

Abilities:

• Ability to work independently and manage own caseload
• Capacity to remain focused despite frequent interruptions (calls, emails, faxes)
• Ability to participate effectively in rounds and communicate clearly with clinical staff
• Flexibility to adapt to changing priorities and payer requirements
• Commitment to accuracy and thorough documentation
• Ability to escalate appropriately when stuck or uncertain
  
  
  

Working Conditions:

• Full-time position, Monday-Friday, with potential for occasional extended hours based on patient needs
• Work is performed in an office setting within a hospital environment
• May require sitting for extended periods while completing computer-based tasks
• Frequent telephone and computer use
• Regular participation in clinical rounds
  
  
  

Benefits:

• Paid Sick Time - effective 90 days after employment
• Paid Vacation Time - effective 90 days after employment
• Health, vision & dental benefits - eligible at 30 days, following the 1st of the following month
• Short and long-term disability and basic life insurance - after 30 days of employment
  
  
  

Disclaimer:

The statements herein are intended to describe the general nature and level of work being performed by employees and are not to be construed as an exhaustive list of functions, tasks, duties, responsibilities and requirements of employees so classified. Furthermore, they do not establish a contract for employment and are subject to change at the discretion of Insight Hospital and Medical Center.

Insight Employees are required to be vaccinated for COVID-19 as a condition of employment, subject to accommodation for medical or sincerely held religious beliefs. Insight is an equal opportunity employer and values workplace diversity!