Utilization Management and Appeals Coordinator

1 week ago

Chicago, Illinois, United States Dr Saleha Khan Full time

Job Description:

We are looking for an International Medical Graduate with clinical experience to assist with our authorization coordination which is part of our utilization management and appeals. This position offers an opportunity to play a key role in improving hospital operations, ensuring proper documentation, and contributing to the overall success of the organization. Additional functions may include accurate review of medical records, determining medical necessity, and submitting appeals. The ideal candidate will have a clinical background, excellent communication skills, and prior experience with clinical documentation improvement (CDI) practices and revenue cycle process would be a plus.

This is an in-office position located at Jackson Park Hospital, IL.

*We are not a temp services company* Salary is commensurate with experience

Key Responsibilities:

  • Review and analyze medical records to determine the medical necessity of services provided.
  • Review of Inpatient Admissions - extraction and creation of necessary report from the EMR System (Paragon) to follow up on the status of inpatient visits
  • Verification that all accounts have an authorization request, validating that all Payor requirements for authorization are completed.
  • Prepare and submit appeals for denied claims (as needed)
  • Utilize clinical criteria such as MCG (Milliman Care Guidelines) and InterQual to support decisions related to medical necessity (as needed)
  • Collaborate with physicians, case managers, and other healthcare providers to ensure accurate documentation and proper coding.
  • Work with a small team of case managers, ensuring efficient workflow and high-quality decision-making.
  • Track and monitor appeal outcomes and identify trends in denials to improve processes.
  • Generate regular reports on key performance indicators (KPIs) related to claims denials, appeals, and overall hospital trends.

Qualifications:

  • International Medical Graduates with Clinical Experience
  • Experience in clinical documentation improvement (CDI), medical necessity determination, and appeals management.
  • Knowledge of MCG, InterQual, and other clinical guidelines is a plus.
  • Experience in medical coding, reimbursement processes, and healthcare regulations is a plus.
  • Strong communication, problem-solving, and organizational skills.
  • Skilled in Excel or Google Sheet
  • Ability to lead a small team and collaborate effectively across departments.
  • Proficiency in healthcare software systems and report generation.

Working Conditions:

  • Full-time position.
  • Office-based, may require hospital visits once/twice a month.

This position offers an opportunity to play a key role in improving hospital operations, ensuring proper documentation, and contributing to the overall success of the organization. If you are a dedicated and experienced professional, we encourage you to apply.

Job Types: Full-time, Contract

Pay: From $25.00 per hour

Benefits:

  • 401(k)
  • Dental insurance
  • Health insurance
  • Life insurance
  • Paid time off
  • Vision insurance

Work Location: In person

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