Utilization Review Coordinator

This is a fully remote position, open to applicants in Maine, +2 more states.

📋 Description

• Evaluate clinical data to assess medical necessity, appropriate levels of care, and length of stay based on standardized clinical criteria.

• Issue positive determinations for cases that meet the criteria and refer other cases for physician peer review.

• Collect relevant clinical information from designated health care providers.

• Verify medical necessity for selected procedures and services.

• Conduct utilization management related to levels of care and duration of stay.

• Consult with Peer Reviewers when the criteria do not support a positive determination or when peer consultation is necessary.

• Promptly screen cases to identify case-management needs and make suitable referrals.

• Follow up on pending utilization-management issues and inquiries.

• Work collaboratively with providers to determine discharge needs and facilitate timely transitions to the appropriate level of care.

• Communicate effectively with providers and other health care professionals regarding the Utilization Management process.

• Maintain case documentation in accordance with established policies and procedures.

• Collaborate with the Manager to foster professional growth.

• Consistently apply standardized criteria and achieve satisfactory quality audit scores.

• Efficiently manage work time and caseload.

• Comply with HIPAA policies and procedures.

⛳️ Requirements

• A minimum of three years of experience in an acute care clinical environment.

• Active, current, and unrestricted professional licensure as an RN or LPN in Massachusetts, Maine, New Hampshire, or the state of residency.

• Proficient in Microsoft Office Suite, including Word, Excel, Outlook, and PowerPoint.

• Familiarity with standardized clinical criteria for medical necessity and utilization management reviews.

• Capability to perform utilization management for levels of care and length of stay.

• Ability to adhere to HIPAA policies and procedures.

• Competence in maintaining documentation in line with policies and procedures.

• Proficiency in managing work time and caseload effectively.

🏝️ Benefits

• Medical, Dental, Vision, and Prescription Drug Coverage.

• Fitness Reimbursement Benefit.

• Employee Assistance Program.

• Flexible Spending Account & Health Savings Account.

• 401(k) plan.

• Quarterly Bonuses.

• Generous Paid-Time Off.

• Opportunities for volunteering.

• Educational Assistance.

• Professional Development Opportunities.

• Smart casual dress code.

• Ergonomic desks.

• Onsite café, office-park trails, and campus gyms available at the Westborough headquarters.