Utilization Management Coordinator

Job Details

Job Location
Texas Institute for Surgery LL SURG - Dallas, TX

Position Type
Full-time

Description

Position TitleDepartmentUtilization Management CoordinatorBusiness OfficeDirect Manager of PositionExempt StatusDirector, Business Services

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False False False Center False 1 NonexemptJob SummaryThe 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.

Qualifications

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

Primary Duties and Responsibilities (listed in order of importance)#Description1Reviews 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.2Applies nationally recognized criteria (e.g., InterQual, MCG) to validate medical necessity for inpatient and outpatient services.3Prepares, 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.4Ensures maximum appropriate payer reimbursement for all services and supplies provided to patients by the hospital.5Collaborates with other coding professionals and services to ensure accurate CPT, ICD-10, and DRG assignment for reimbursement optimization.6Drafts and submits detailed appeals for denied claims, including clinical justification and supporting documentation.7Assists and facilitates the physician peer-to-peer review process with payers.8Provides consultation to medical and nursing staff, RN Care Coordinator, Health Information Management (HIM), and revenue cycle personnel on potential issues with reimbursement.9Works closely with the RN Care Coordinator to support discharge planning activities.10Tracks 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.11Prepares documentation and supports audit activities related to utilization review and reimbursement. Assists in responding to audit findings and implementing corrective action plans.12Adheres to best practices, including CMS guidelines, CIHQ standards, and state laws governing medical necessity and Case Management Standards.13Participates in UR Committee.14Performs other duties and special projects as assigned to support departmental and organizational goals.

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