Utilization Review Coordinator
6 days ago
Job DescriptionJob SummaryThe Utilization Review Coordinator ensures efficient and effective management of utilization review processes, including denials and appeals activities. This role collaborates with payers, hospital staff, and clinical specialists to secure timely authorizations for hospital admissions and extended stays. The Utilization Review Coordinator monitors and documents all authorization activities, assists with process improvement initiatives, and serves as a key liaison to reduce denials and optimize patient outcomes.Essential Functions Submits initial assessments, continued stay reviews, and payer-requested documentation, ensuring compliance with policies, regulations, and payer requirements to establish medical necessity. Communicates with commercial payers to provide concise and accurate information to secure timely authorizations and reduce potential denials, utilizing input from the Utilization Review Clinical Specialist. Monitors and updates case management software with documentation of escalations, avoidable days, authorization numbers, denials, and payer interactions to ensure accurate records. Coordinates Peer-to-Peer discussions for unresolved concurrent denials, ensuring the process aligns with hospital, corporate, and payer requirements. Documents outcomes in case management systems. Reviews and closes out cases after patient discharge, ensuring all required documentation is complete and understandable for billing and future audits. Places cases on hold as necessary to resolve pending authorizations or reviews. Maintains performance metrics aligned with Key Performance Indicators (KPIs) for the Utilization Review Service Line. Serves as a key contact for facility and payer representatives, fostering effective communication and collaboration to resolve issues promptly. Participates in training initiatives within the department, supporting onboarding and skill development for team members. Responds promptly to phone calls, faxes, and insurance portal requests, providing high standards of customer service and satisfaction. Escalates issues to the manager as appropriate and provides recommendations for improving operational efficiency and outcomes. Ensures accurate and timely communication of hospital stay authorizations, denials, and delays to all relevant stakeholders. Performs other duties as assigned. Maintains regular and reliable attendance. Complies with all policies and standards. Qualifications H.S. Diploma or GED required Bachelor's Degree preferred 0-2 years of work experience in utilization review, hospital admissions or registration required 1-3 years of work experience in an office, processing center, or similar environment preferred Knowledge, Skills and Abilities Strong knowledge of utilization management principles, payer requirements, and healthcare regulations. Proficiency in case management systems and technology resources for authorization tracking and documentation. Excellent communication and interpersonal skills to interact effectively with payers, clinicians, and administrative staff. Critical thinking and problem-solving skills to analyze and resolve authorization and denial issues. Strong organizational skills to manage multiple priorities and meet deadlines. Attention to detail for accurate documentation and process adherence. Ability to train and support team members, fostering a collaborative and productive environment.
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RN Utilization Specialist/Review Nurse
2 weeks ago
Brentwood, United States Utilization Management 99610 Full timeJoin YesCare: A Career with Purpose in Correctional HealthcareCorrectional healthcare is more than just a job—it’s a calling. At YesCare, you have the unique opportunity to make a meaningful difference in the health, well-being, and future of an underserved population.As a pioneer in correctional healthcare services, YesCare is committed to innovation,...
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RN Utilization Specialist/Review Nurse
2 weeks ago
Brentwood, United States Utilization Management 99610 Full timeUtilization Management 99610 - Join YesCare: A Career with Purpose in Correctional HealthcareCorrectional healthcare is more than just a job—it’s a calling. At YesCare, you have the unique opportunity to make a meaningful difference in the health, well-being, and future of an underserved population.As a pioneer in correctional healthcare services,...
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Clinical Utilization Review Specialist
6 days ago
Brentwood, United States Community Health Systems Full timeJob DescriptionJob SummaryThe Clinical Utilization Review Specialist is responsible for evaluating the necessity, appropriateness, and efficiency of hospital services to ensure compliance with utilization management policies. This role conducts admission and continued stay reviews, supports denials and appeals activities, and collaborates with healthcare...
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PRN Clinical Utilization Review Specialist
6 days ago
Brentwood, United States Community Health Systems Full timeJob DescriptionJob SummaryThe Remote PRN Clinical Utilization Review Specialist is responsible for evaluating the necessity, appropriateness, and efficiency of hospital services to ensure compliance with utilization management policies. This role conducts admission and continued stay reviews, supports denials and appeals activities, and collaborates with...
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MDS Coordinator
4 weeks ago
Brentwood, United States HC&N Healthcare Solutions Full timeMDS Coordinator A nursing home is currently looking for a highly experienced MDS Coordinator to join their team of dedicated professionals. Responsible for completion of the Resident Assessment Instrument in accordance with federal and state regulations and company policy and procedures. Acts as in-house case manager by considering all aspects of the...
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MDS Coordinator
2 weeks ago
Brentwood, United States HC&N Healthcare Solutions Full timeHC&N Healthcare Solutions - MDS Coordinator A nursing home is currently looking for a highly experienced MDS Coordinator to join their team of dedicated professionals. Responsible for completion of the Resident Assessment Instrument in accordance with federal and state regulations and company policy and procedures.Acts as in-house case manager by considering...
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Registered Nurse
4 days ago
Brentwood, TN, United States Williamson Health Full timeSummary ABOUT WILLIAMSON HEALTH | Williamson Health is a regional healthcare system based in Williamson County, Tennessee, with more than 2,300 employees across more than 30 locations and more than 860 physicians and advanced care practitioners offering exceptional healthcare across 60-plus specialties and subspecialties close to home. The flagship facility,...
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MDS Coordinator
5 days ago
Brentwood, NY, United States HC&N Healthcare Solutions Full timeMDS Coordinator A nursing home is currently looking for a highly experienced MDS Coordinator to join their team of dedicated professionals. Responsible for completion of the Resident Assessment Instrument in accordance with federal and state regulations and company policy and procedures. Acts as in-house case manager by considering all aspects of the...
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MDS Coordinator
2 days ago
Brentwood, NY, United States HC&N Healthcare Solutions Full timeMDS Coordinator A nursing home is currently looking for a highly experienced MDS Coordinator to join their team of dedicated professionals. Responsible for completion of the Resident Assessment Instrument in accordance with federal and state regulations and company policy and procedures. Acts as in-house case manager by considering all aspects of the...
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Steel Shop Drawing Reviewer
14 hours ago
Brentwood, Tennessee, United States Apex Structural Engineering Full timeLocation:Nashville, TNAbout Us:At Apex Structural Engineering, we pride ourselves on fostering a collaborative and innovative work environment. We are committed to advancing the field of structural engineering while ensuring our team has access to top-notch amenities and a supportive, family-friendly culture. Our office is equipped with state-of-the-art...
