Utilization Management Appeals Coordinator

1 day ago

Chicago, Illinois, United States Southwest Healthcare System Full time

Responsibilities JOB SUMMARY: Responsible for all denial and appeal activities for the Utilization Management department, including Expedited Appeals, Standard Appeals, External Independent Reviews, Retrospective Reviews, and State Fair Hearings. Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity of services requested. Prepare letters for member and provider appeals that did not meet criteria. Gather, analyze, and report information regarding member and provider appeals. Maintain files and logs for all appeals. Follow all appeals and retrospective reviews through resolutions. Remain current on applicable UM trends and regulations and review current policies and procedures for compliance. Work closely with the Business Office to ensure proof of authorization and denials communicated accurately in Midas. Interface with various managed care organizations and other payers to resolve issues related to appeals. Maintains all records/data pertaining to the Utilization Management Program. Actively participates in Utilization Management/Medical Records Committee meetings including presentation of reports, statistics, etc. Participates in the hospital-wide Quality Assurance Program. Qualifications JOB SPECIFICATIONS: To perform this job successfully, an individual must be able to perform each primary duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Education: Bachelor's Degree in behavioral health related field required; Master Degree preferred. Experience: 1 year experience in Utilization Management and 1 year experience in mental health/psychiatry preferred. Knowledge: Possesses knowledge of utilization review, insurance and managed care procedures. Current knowledge of regulating /accrediting agency guidelines. Basic knowledge of computer skills and statistical analysis desired. Knowledgeable in behavioral health managed care and clinical assessment skills to align patient acuity with level of care practice guidelines - Diagnostic and Statistical Manual of Mental Disorders (DSM-V). Effective oral and written communication skills to support patient advocacy/negotiating skills to ensure quality reviews with payers.

  • Utilization Management Appeals Coordinator

    2 hours ago

    Chicago, Illinois, United States Southwest Healthcare System Full time

    Job Summary:Responsible for all denial and appeal activities for the Utilization Management department, including Expedited Appeals, Standard Appeals, External Independent Reviews, Retrospective Reviews, and State Fair Hearings.The Denial and Appeal Specialist reviews clinical information for all appeals utilizing nationally recognized criteria to determine...

  • Utilization Management Appeals Coordinator

    14 hours ago

    Chicago, Illinois, United States Hartgrove Behavioral Health System Full time

    Job Description Responsibilities JOB SUMMARY: Responsible for all denial and appeal activities for the Utilization Management department, including Expedited Appeals, Standard Appeals, External Independent Reviews, Retrospective Reviews, and State Fair Hearings. Review clinical information for all appeals utilizing nationally recognized...

  • Clinical Appeals Coordinator

    2 weeks ago

    Chicago, Illinois, United States beBee Careers Full time

    Appeals and Denials CoordinatorWe are seeking a highly skilled Clinical Appeals Coordinator to join our team. As a Clinical Appeals Coordinator, you will be responsible for coordinating all aspects of the appeals process.Main Responsibilities:Review clinical information for all appeals utilizing nationally recognized criteria to determine medical necessity...

  • Utilization Coordinator

    2 weeks ago

    Chicago, Illinois, United States beBee Careers Full time

    **Job Summary:**We are seeking a highly organized and detail-oriented Utilization Coordinator to join our team. As a Utilization Coordinator, you will play a critical role in coordinating the utilization review and appeals process.Responsibilities:Coordinate phone calls with insurance providers and health plansData entry and tracking of authorization,...

  • Utilization Coordinator

    2 weeks ago

    Chicago, Illinois, United States beBee Careers Full time

    Job DescriptionJob SummaryWe are seeking a skilled Utilization Reviewer to join our team. The ideal candidate will be responsible for coordinating the utilization review and appeals process, working closely with insurance providers and health plans to ensure timely and accurate reviews.Key Responsibilities:Coordinate phone calls, data entry, and...

  • Utilization Management Coordinator

    15 hours ago

    Chicago, Illinois, United States Southwest Healthcare System Full time

    Utilization Management SpecialistJoin our team in ensuring timely and accurate clinical reviews to secure authorization for treatment based on payer criteria.Responsibilities:Perform daily clinical reviews with all payer types to secure authorization for initial and continued treatmentServe as liaison to 3rd and 4th party reviewers, coordinating data...

  • Utilization Management Coordinator

    7 hours ago

    Chicago, Illinois, United States Southwest Healthcare System Full time

    Responsibilities JOB SUMMARY: Performs timely, daily clinical reviews with all payer types, to secure authorization for initial and continued treatment based on payer's criteria and in accordance with the hospital wide Utilization Management Plan. Serves as liaison to 3rd and 4th party reviewers, effectively coordinating collection of all supporting data to...

  • Utilization Management Coordinator

    5 hours ago

    Chicago, Illinois, United States Garfield Park Behavioral Hospital Full time

    Job DescriptionResponsibilitiesJob Summary: The Utilization Management Specialist plays a critical role in ensuring timely and effective clinical reviews with payers to secure authorization for patient treatment. This involves serving as a liaison between the hospital, payers, and multidisciplinary treatment teams to educate and guide on level of care...

  • Appeals and Denials Specialist

    2 weeks ago

    Chicago, Illinois, United States beBee Careers Full time

    Job SummaryWe are seeking a highly skilled Appeals and Denials Specialist to join our team. As an Appeals and Denials Specialist, you will be responsible for all denial and appeal activities for the Utilization Management department.Main Responsibilities:Review clinical information for all appeals utilizing nationally recognized criteria to determine medical...

  • Utilization Management Coordinator

    8 hours ago

    Chicago, Illinois, United States Southwest Healthcare System Full time

    Job Title: Clinical Reviewer - Utilization ManagementWe are seeking a skilled and detail-oriented Clinical Reviewer to join our Utilization Management team. As a key member of the multidisciplinary treatment team, you will be responsible for performing timely daily clinical reviews with all payer types to secure authorization for initial and continued...