Utilization Management Coordinator

The Utilization Management Coordinator supports Insurance Verification (IV) by securing pre-certification for patients requiring authorizations. This role performs telephonic and concurrent reviews of inpatient hospitalizations and extended outpatient services. The UM Coordinator plays a key role in overturning denials and reviewing reimbursement eligibility for services rendered. They apply healthcare knowledge, utilization management expertise, product benefit understanding, regulatory awareness, and nationally recognized criteria to assess medical necessity.

Essential Duties and Responsibilities:

1. Reviews clinical documentation to ensure compliance with payer-specific medical necessity requirements and coding standards. Provides education and guidance to physicians on documentation best practices to support accurate coding and optimal reimbursement.
2. Applies nationally recognized criteria (e.g., InterQual, MCG) to validate medical necessity for inpatient and outpatient services.
3. Prepares, drafts, and submits clinical documentation to payers to support authorization requests, including pre-admission approvals, extensions for additional days of stay, and appeals to overturn payment denials.
4. Ensures maximum appropriate payer reimbursement for all services and supplies provided to patients by the hospital.
5. Collaborates with other coding professionals and services to ensure accurate CPT, ICD-10, and DRG assignment for reimbursement optimization.
6. Drafts and submits detailed appeals for denied claims, including clinical justification and supporting documentation.
7. Assists and facilitates the physician peer-to-peer review process with payers.
8. Provides consultation to medical and nursing staff, RN Care Coordinator, Health Information Management (HIM), and revenue cycle personnel on potential issues with reimbursement.
9.  Works closely with the RN Care Coordinator to support discharge planning activities.
10. Tracks and analyzes denial reasons to identify systemic issues and recommend process improvements. Assists in aggregating data for quality trending. Participates in process improvement initiatives as required.
11. Prepares documentation and supports audit activities related to utilization review and reimbursement. Assists in responding to audit findings and implementing corrective action plans.
12. Adheres to best practices, including CMS guidelines, CIHQ standards, and state laws governing medical necessity and Case Management Standards.
13. Participates in UR Committee.
14. Performs other duties and special projects as assigned to support departmental and organizational goals.

• Education & Training:
  • Associate’s degree in healthcare administration, nursing, or related field, required.
  • Bachelor’s degree in nursing, Healthcare Administration, or Business Administration, preferred.
  • Coursework or certification in medical billing, coding, or healthcare compliance, preferred.
• Experience:
  • Minimum of 2 years in Utilization Management in an acute care setting, required.
  • At least 1 year of experience drafting and submitting reconsiderations and appeals to payers.
  • Preferably 2 years of experience using InterQual or Milliman criteria.
• Licensure/Certification/Registration:
  • Current Texas RN license required
  • Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), or Certified Professional Coder (CPC), preferred
  • Orthopedic coding certification preferred (e.g., COSC)
• Key Skills:
  • Strong knowledge of CPT, ICD-10-CM, ICD-10-PCS, HCPCS, and DRG grouping systems.
  • Proficiency in EHR and billing systems (CPSI, Epic, Cerner, or similar).
  • Excellent written and verbal communication.
  • Detail-oriented with strong organizational and analytical abilities.
  • Understanding of payer medical policies, appeals processes, and revenue cycle management.

We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by applicable law.