Utilization Coordinator

We are seeking a detail-oriented and experienced Utilization Coordinator to manage the insurance prior authorization process on a part-time, remote basis. This role is focused exclusively on authorization requests submitted via fax and payer portals — from initial clinical documentation gathering through submission, status tracking, and resolution.

The Utilization Coordinator works at the intersection of clinical operations and insurance compliance. They are responsible for ensuring that authorization requests are submitted accurately, on time, and with the right clinical documentation — and for following the authorization through to approval, denial, or peer-to-peer review. This is a deadline-driven, detail-intensive role that requires someone who is organized, persistent, and familiar with the payer authorization landscape.

Key Responsibilities

Authorization Request Submission

• Review incoming authorization requests and identify all required clinical documentation for each payer and service type
• Submit prior authorization requests to insurance carriers via fax and payer portals within each payer's required timeframe
• Ensure all submitted requests are complete, accurate, and include the appropriate supporting clinical documentation to avoid unnecessary delays or denials
• Maintain working knowledge of payer-specific authorization requirements, submission methods, and timelines across all relevant insurance carriers

Clinical Documentation Gathering

• Coordinate with the clinical and medical teams to gather necessary documentation for authorization requests, including clinical notes, treatment plans, physician orders, and supporting records
• Follow up proactively with clinical staff when documentation is incomplete, missing, or requires additional detail to meet payer criteria
• Communicate clearly with internal teams about what is needed, why it is needed, and the urgency of the timeline
• Ensure all clinical documentation is organized, complete, and appropriately formatted before submission

Authorization Status Tracking

• Maintain an accurate and up-to-date tracking log of all submitted authorization requests, pending decisions, and authorization statuses
• Monitor payer portals and fax queues regularly for updates, approvals, denials, and requests for additional information
• Proactively follow up with payers on pending authorizations that are approaching deadlines or have not received timely responses
• Communicate authorization status updates to relevant internal stakeholders, including clinical and billing teams, as decisions are received

Peer-to-Peer Review Coordination

• Identify cases where a peer-to-peer review has been requested by the payer or may be beneficial following a denial
• Coordinate peer-to-peer review scheduling between the payer and the appropriate treating or ordering provider
• Prepare relevant clinical documentation and case summaries to support the provider in advance of the peer-to-peer call
• Follow up on peer-to-peer outcomes and ensure the resulting authorization decision is documented and acted upon appropriately

Issue Resolution & Follow-Up

• Identify and troubleshoot authorization delays, payer requests for additional information, and other barriers to timely approval
• Escalate complex denials, coverage disputes, or payer issues to the appropriate internal team member with thorough documentation
• Maintain a follow-up schedule for open authorization issues and ensure nothing is left unresolved or unmonitored
• Communicate resolution outcomes to clinical, billing, and operational stakeholders as appropriate

Required Qualifications

• Prior experience in a utilization management, prior authorization, or insurance authorization role in a healthcare setting
• Solid understanding of the insurance prior authorization process including submission via fax and payer portals
• Familiarity with payer-specific authorization requirements and the ability to navigate multiple payer portals efficiently
• Experience coordinating with clinical teams to gather and organize medical documentation for authorization submissions
• Strong attention to detail and organizational skills — authorization requests must be accurate, complete, and submitted on time
• Comfortable managing a tracking system for multiple open authorization cases simultaneously
• Reliable and self-directed in a remote work environment — deadlines are firm and follow-up is expected without prompting
• Clear written and verbal communication skills for coordinating with clinical staff and internal stakeholders

Preferred Qualifications

• Experience coordinating peer-to-peer reviews between payers and treating providers
• Familiarity with medical necessity criteria frameworks such as InterQual or MCG (Milliman Care Guidelines)
• Background in behavioral health, specialty care, or a high-authorization-volume clinical setting
• Experience using electronic health record (EHR) systems and insurance payer portals for authorization management
• Knowledge of HIPAA regulations and proper handling of protected health information ( PHI )