Utilization Review Coordinator

EOE Statement We are an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status or any other characteristic protected by law. Description Position Summary The UR and RCM Support Coordinator is responsible for securing and maintaining payer authorizations across all levels of care for residential substance use disorder (SUD) treatment, including ASAM Levels 3.5 and 3.7, while also providing cross-functional support to the Revenue Cycle Management department. This role serves as a key link between the clinical team, payers, and the RCM department, ensuring that medical necessity is clearly documented, communicated, and defended throughout each patient's episode of care. Reporting to the Director of Utilization Review with a dotted-line relationship to the Director of Revenue Cycle Management, the UR and RCM Support Coordinator works in close partnership with billing, denials, appeals, and clinical leadership to drive authorization approval rates, prevent denials at the front end, and protect revenue across the multi-state network of facilities. This is a high-visibility role with direct impact on length of stay, denial rates, and net collections. Essential Duties and Responsibilities Authorization Management Complete pre-certification, initial, concurrent, and discharge reviews with commercial, Medicaid, and Medicaid managed care payers for residential SUD levels of care (ASAM 3.1, 3.5, 3.7, and detox where applicable). Submit clinical information to payers within required timeframes, using ASAM criteria and payer-specific medical necessity guidelines to justify admission, continued stay, and level of care. Track all authorization requests, approvals, days approved, next review dates, and denials in the UR tracking system; ensure no patient day is at risk due to a missed or expired authorization. Escalate authorization issues, denials, or peer-to-peer requests to the Director of Utilization Review and Director of RCM in real time, along with clinical leadership as appropriate. Peer-to-Peer and Denial Prevention Coordinate, prepare, and schedule peer-to-peer reviews between facility physicians and payer medical directors; provide the rendering clinician with a written summary of medical necessity points prior to each call. Document peer-to-peer outcomes, including outcome reason, reviewer name, and any payer-specific feedback for use in future submissions. Partner with the Director of Utilization Review and Director of RCM, along with the appeals team, to identify trends in concurrent denials and translate findings into documentation and clinical workflow improvements. Support the appeals process by providing UR notes, clinical timelines, and the authorization history needed for first- and second-level appeals. Clinical Documentation Partnership Review clinical documentation daily for alignment between the billed level of care and the documented level of care; flag and address mismatches before they generate denials (a known driver of pre-payment review and payer recoupment risk). Provide real-time coaching and written feedback to clinicians, therapists, and medical providers on documentation elements required to meet ASAM 3.5 and 3.7 medical necessity (e.g., dimensional risk ratings, withdrawal management needs, biomedical and behavioral complications, treatment response, and continued-stay justification). Partner with clinical leadership to maintain documentation templates and standards that satisfy commercial payer, state Medicaid, and accreditation requirements across Arkansas, Colorado, Indiana, Kentucky, and Ohio. Revenue Cycle Coordination Work alongside the RCM team to support resolution of authorization-driven holds, write-off recommendations, and pre-payment review responses, providing UR expertise and clinical context as needed. Provide the billing team with accurate authorization numbers, approved date ranges, level-of-care designations, and modifier guidance to ensure clean claim submission. Participate in standing meetings with the Director of Utilization Review, Director of RCM, billing manager, and denials/appeals leads to review denial trends, hold billing volume, AR aging by payer, and authorization-related risk. Contribute to executive-facing reporting on UR performance, including authorization approval rates, average days authorized, peer-to-peer outcomes, and denial root cause. Support the RCM team as needed with cash posting, billing, and denial reconciliation activities, particularly during peak volume, staff coverage gaps, or special projects. Participate in the implementation, testing, and rollout of new software platforms, payer portals, and operational processes; provide UR-side workflow input, validate functionality, and assist with end-user training and adoption across facilities. Payer Relationships and Compliance Maintain working knowledge of payer-specific medical necessity criteria, review timelines, submission portals, and documentation requirements for Ambetter, UnitedHealthcare, Optum, Aetna, Cigna, Anthem/Elevance, Colorado Access, state Medicaid programs, and Medicaid managed care plans operating in network states. Track payer policy changes, level-of-care criteria updates, and contract requirements; communicate impact to RCM and clinical leadership. Support payer pre-payment reviews, audits, and medical record requests by assembling complete UR packets within required timeframes. Maintain strict compliance with HIPAA, 42 CFR Part 2, state confidentiality laws, and organizational policy in all payer communications. Position Requirements Qualifications Required Active, unrestricted clinical license in good standing (RN, LPN, LCSW, LPC, LMFT, LCDC/LADC, or equivalent behavioral health license) OR equivalent UR experience acceptable to the organization. Minimum of 2 years of utilization review, case management, or care coordination experience in behavioral health, substance use disorder, or mental health treatment. Demonstrated working knowledge of ASAM Criteria, with the ability to apply dimensional assessments to medical necessity submissions. Direct experience completing concurrent reviews with commercial and/or Medicaid payers for residential SUD or behavioral health levels of care. Strong written and verbal communication skills, with the ability to summarize complex clinical information into concise medical necessity language. Proficient in electronic health records, payer portals, and Microsoft Office (Excel, Word, Outlook, Teams). Preferred Experience supporting multi-state operations or multi-facility provider networks. Prior experience working within or alongside a Revenue Cycle Management department, including familiarity with denials, appeals, and AR workflows. Working knowledge of state Medicaid behavioral health billing requirements (e.g., Ohio rendering practitioner/NPI rules, Colorado HCPF supervising clinician and modifier requirements, Kentucky and Indiana ASAM billing structures, Arkansas OBHS billing). Experience handling pre-payment reviews and supporting payer audit responses. Knowledge, Skills, and Abilities Ability to think both clinically and financially - to recognize when documentation will not support the billed level of care and intervene before claims are submitted. Strong organizational skills and the ability to manage a high volume of concurrent reviews across multiple facilities, payers, and time zones without missing deadlines. Comfort working independently in a remote environment while maintaining tight collaboration with clinical, billing, and leadership teams. Sound judgment in escalating risk: when to request a peer-to-peer, when to engage the Director of Utilization Review or Director of RCM, and when to involve clinical leadership. Discretion and professionalism in all payer-facing communications; the UR Coordinator represents the organization to payer medical directors and case managers. Key Performance Indicators Performance will be evaluated against, but not limited to, the following measures: Initial authorization approval rate by payer and level of care. Concurrent review approval rate and average days approved per review. Peer-to-peer overturn rate. Concurrent denial rate and root-cause distribution (medical necessity vs. documentation vs. timeliness). Timeliness of review submission (meeting or exceeding payer deadlines). Authorization-related hold billing volume and aging. Working Conditions and Physical Requirements Primarily remote, office-based work; extended periods of computer and phone use. Standard business hours with occasional flexibility required to meet payer deadlines or accommodate peer-to-peer scheduling across time zones. Occasional travel to facilities or payer meetings may be required. Full-Time/Part-Time Full-Time Shift -not applicable- Position Utilization Review Coordinator Division Sheridan Grove Recovery Number of Openings 1 Exempt/Non-Exempt Non-Exempt Hiring Manager(s) Tracy Polk Location DEN1 About the Organization Healing with Dignity, Recovery with Purpose. Oak Grove Recovery proudly serves the Columbus, Ohio community by providing compassionate, judgment-free addiction treatment. Our dedicated team is available 24/7 to support each individual on their healing journey, offering care rooted in dignity, purpose, and unwavering respect. This position is currently accepting applications. #J-18808-Ljbffr Sheridan Grove Recovery