Care Management UR Coodinator

Job Description

Job Description

Description :

Summary : The Utilization Review Coordinator supports the Care Management Department by facilitating the intake, review, and coordination of authorization requests. This position ensures timely and accurate processing of both prospective and retrospective utilization review activities in accordance with company policies, benefit plans, and medical necessity guidelines.

Essential Duties and Responsibilities : Duties include, but are not limited to, the following. Other tasks may be assigned as needed.

• This is an on-site position .
• Must be able to work 8 : 30 am to 5 pm, Monday through Friday.
• Maintain strict confidentiality and compliance with HIPAA and internal privacy policies.
• Accurately receive, review, and route incoming authorization requests to the appropriate reviewer.
• Enter and update all utilization review data in the medical management system with accuracy and completeness.
• Review submitted medical documentation for consistency between diagnosis, services requested, and clinical information.
• Verify member eligibility and benefits to support determination of coverage.
• Apply established medical criteria and internal guidelines to assist in the review process.
• Prepare documentation and recommendations for licensed clinical staff and medical directors as part of the determination process.
• Communicate effectively with providers, members, clients, and internal departments regarding authorization requests, status updates, and required information.
• Respond to inbound calls from providers and members in the department’s phone queue, offering professional and accurate assistance.
• Provide backup administrative support as needed, including phones, correspondence, and data entry.
• Perform other duties as assigned by management.

Supervisory Responsibilities : This position has no supervisory responsibilities.

Work Environment : The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

Requirements :

Knowledge, Skills, and Abilities :

Supervisory Responsibilities : This position has no supervisory responsibilities.

Qualifications :

Language Skills :

Mathematical Skills :

Reasoning Ability :

Certificates, Licenses, and Registrations :

Physical Demands : The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit for extended periods in front of a computer. The employee is frequently required to reach with hands and arms and talk or hear. The employee is occasionally required to stand; walk and use hands to finger, handle, or feel. The employee may frequently lift and / or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus. This position requires the employee to work in the office.