Utilization Coordinator

This is a fully remote position, open to applicants in Philippines.

📋 Description

• Assess incoming authorization requests and determine all necessary clinical documentation for each payer and service type.

• Submit prior authorization requests to insurance providers via fax and payer portals within the required timeframe of each payer.

• Ensure that all submitted requests are complete, accurate, and accompanied by the appropriate supporting clinical documentation to prevent unnecessary delays or denials.

• Maintain a thorough understanding of payer-specific authorization requirements, submission methods, and timelines across all relevant insurance carriers.

• Collaborate with clinical and medical teams to collect essential documentation for authorization requests, including clinical notes, treatment plans, physician orders, and supporting records.

• Proactively follow up with clinical staff when documentation is incomplete, missing, or needs additional detail to comply with payer criteria.

• Clearly communicate with internal teams regarding what is needed, the reasons for the request, and the urgency of the timeline.

• Ensure all clinical documentation is organized, complete, and correctly formatted prior to submission.

• Maintain an accurate and updated tracking log of all submitted authorization requests, pending decisions, and authorization statuses.

• Regularly check payer portals and fax queues for updates, approvals, denials, and requests for further information.

• Proactively follow up with payers on pending authorizations nearing deadlines or those that have not received timely responses.

• Provide authorization status updates to relevant internal stakeholders, including clinical and billing teams, as decisions are made.

• Identify instances where a peer-to-peer review has been requested by the payer or may be advantageous following a denial.

• Coordinate the scheduling of peer-to-peer reviews between the payer and the appropriate treating or ordering provider.

• Prepare relevant clinical documentation and case summaries to support the provider prior to the peer-to-peer call.

• Follow up on peer-to-peer outcomes and ensure that the resulting authorization decision is documented and acted upon accordingly.

• Identify and troubleshoot delays in authorization, payer requests for additional information, and other obstacles to timely approval.

• Escalate complex denials, coverage disputes, or payer issues to the appropriate internal team member with comprehensive documentation.

• Maintain a follow-up schedule for outstanding authorization issues to ensure nothing remains unresolved or unmonitored.

• Communicate resolution outcomes to clinical, billing, and operational stakeholders as appropriate.

⛳️ Requirements

• Prior experience in utilization management, prior authorization, or insurance authorization roles within a healthcare setting.

• Strong understanding of the insurance prior authorization process, including submissions via fax and payer portals.

• Familiarity with payer-specific authorization requirements and the ability to efficiently navigate multiple payer portals.

• Experience in coordinating with clinical teams to gather and organize medical documentation for authorization submissions.

• Exceptional attention to detail and organizational skills — authorization requests must be accurate, complete, and submitted promptly.

• Comfortable managing a tracking system for multiple open authorization cases concurrently.

• Reliable and self-motivated in a remote work environment — adherence to deadlines is crucial, and follow-up is expected without prompting.

• Strong written and verbal communication skills for effective coordination with clinical staff and internal stakeholders.

• Experience in 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 environment.

• Experience utilizing electronic health record (EHR) systems and insurance payer portals for authorization management.

• Knowledge of HIPAA regulations and proper handling of protected health information (PHI).

🏝️ Benefits

• Competitive salary.

• Comprehensive health benefits package.

• Opportunities for professional development and growth.

• Flexible work environment.

• Supportive team culture.