Utilization Review Coordinator

Deliverables / Principal Results Expected Perform admission, continued stay and discharge reviews on all managed care clients. Maintain positive relationships with referral sources and insurance companies. Track admissions, continued stay and discharge ASAM requirements for county referrals. Maintain organized system of reporting to counselors when ASAMs are due and when review calls are to be made. Maintain current insurance eligibility information through EVS, Navinet, etc. Monitor census for accuracy of funding. Attend clinical staffing to obtain information for client reviews. Maintain daily UR database accurately. Perform Act 106 reviews and follow up appeals. Track all county referrals for documentation of admission calls. Maintain and participate in chart reviews to ensure proper paperwork is in place. Work directly with Billing Department to reduce uncovered days of funding. Investigate cases with insurance and referral sources to recuperate lost days of funding. Report to the Assessment Manager on a weekly basis. Manage all self-pay clients and clients with copays, deductibles, coinsurance and liabilities. Reduce client balances. Other duties as assigned. Technical Competencies Provide the company with accurate information to ensure full financial coverage for each client day. Provide the referral source(s) with timely information to ensure good customer focus. Maintain client confidentiality and provide a safe therapeutic treatment. Knowledge of local, state and federal regulations. Knowledge of facility contracts and agreements. Knowledge of medical terminology, appeal and denial process, composition of medical records. Knowledge of data entry (primarily Excel) and mathematics. Knowledge of pre-certification process and ASAM. Knowledge of CARF standards, release of information and confidentiality. Knowledge of DSM V, private care managers and county referral sources. Education & Experience Associate Degree or equivalent required; Bachelor of Science in Behavioral Health. Intermediate knowledge of computer skills and the internet, Microsoft Office experience, Excel—Intermediate level, Word—Intermediate level. 3-5 years’ experience in Utilization Review or related position in a healthcare setting. Job-Related Behavioral Characteristics Demonstrates professionalism, leadership, confidentiality, strong social communication skills, time‑management, organized. Must possess skills to communicate effectively and interact well with people of diverse backgrounds. Excellent oral and written communication and interpersonal skills. Ability to problem‑solve by gathering and analyzing information, working well in an individual/group problem‑solving situation, and showing initiative in problem solving. Maintains professionalism and does not show favoritism. Maintains consistency with clients, staff, visitors, and the public. Ability to handle a crisis situation and react appropriately. Flexibility and adaptability. Ability to make decisions in an objective and ethical manner. Calm and decisive in crisis situations. Ability to sustain a team environment, drive continuous improvement projects, confidentiality, excellent problem‑solving skills and excellent communicator within the team framework. Self‑starter, takes initiative. Core Values INTEGRITY – striving to be honest, transparent, and ethical when dealing with clients, staff, and the community. DEDICATION – demonstrating an unwavering commitment to always provide exceptional care and support to those we serve. COLLABORATION – a steadfast, team‑focused approach; working together to achieve excellence. PASSION – genuine, compelling, and relentless desire to improve lives and support Pyramid Healthcare’s mission. Equal Opportunity Statement Pyramid Healthcare, Inc. is proud of its diverse workforce, and is an Equal Opportunity Employer. #J-18808-Ljbffr