Lead Utilization Management Coordinator

This is a fully remote position, open to applicants in Virginia, +1 more state.

📋 Description

• Provide strategic oversight, execution, and management of concurrent denials to ensure timely authorizations, avert appeals, and enhance institutional reimbursement.

• Act as an advanced clinical and operational leader in utilization management, medical necessity, patient status determination, payor behaviors, and intricate appeal strategies.

• Support quality assurance frameworks and ongoing monitoring protocols for team performance and compliance.

• Mentor utilization management coordinators and collaborate with the Physician Advisor and Clinical Appeals teams to drive process improvements.

• Create denial-prevention strategies and educational programs.

• Guide and mentor team members through workflow observation, skill-gap analysis, real-time feedback, and action-item tracking.

• Oversee daily operations, meet deadlines, and ensure adequate staffing coverage.

• Present performance improvement opportunities, quality assurance concerns, and KPI results to leadership.

• Serve as a subject matter expert and primary contact for staff inquiries, orientation, education, process initiatives, and document management.

• Evaluate concurrent denials and determine subsequent steps, including peer-to-peer requests, billing-status modifications, additional clinical information, and Clinical Appeals referrals.

• Analyze medical records and suggest denial-management actions based on clinical expertise and payor behaviors.

• Collaborate with leadership, contracting, physicians, UR coordinators, Clinical Appeals, and interdisciplinary teams.

• Advocate with insurance companies to maximize reimbursement and hospital stay coverage.

• Manage utilization-management processes in accordance with Medicare Conditions of Participation and federal and state regulations.

• Analyze project metrics and stay updated on payor requirements and relevant regulations.

• Provide reconsideration clinicals to payors and facilitate patient-centered authorization processes.

• Ascertain appropriate admission status based on regulatory and reimbursement guidelines.

• Engage in process improvement initiatives and handle a diverse workload in a fast-paced regulatory setting.

• Coordinate physician communications to guarantee appropriate patient status.

• Deliver continuous orientation, training, and competency development.

• Act as a role model and change agent, fostering teamwork and enhancing revenue-cycle performance.

⛳️ Requirements

• Active Registered Nurse license from the state where services will be rendered, or a current multi-state RN license via the enhanced Nurse Licensure Compact (eNLC).

• Minimum of four years of clinical experience in a hospital environment.

• At least five years of experience in Utilization Review and/or Clinical Appeals and/or case management.

• Bachelor’s Degree in Nursing is preferred.

• Familiarity with medical terminology.

• Understanding of third-party payers.

• Proficient in computer usage.

• Strong verbal and written communication abilities.

• Excellent interpersonal skills.

• High attention to detail.

• Capability to exercise tact and diplomacy.

• Outstanding customer service and telephone etiquette.

• Ability to read and comprehend effectively.

• Visual acuity within normal limits.

• Proficient communication skills.

• Manual dexterity for operating keyboards, fax machines, telephones, and other office equipment.

• Ability to maintain a confidential home office environment.

• Willingness to work assigned weekends and holidays.

🏝️ Benefits

• Flexible remote work arrangement.

• Confidential home office environment.

• Required work on weekends and holidays as assigned.

• Reasonable accommodations may be provided for individuals with disabilities.