Utilization Management Coordinator - Greenville Ave, Suite Dallas, Texas, United States
18 hours ago
Job description
DescriptionThe Utilization Management Coordinator supports Insurance Verification (IV) by securing pre-certification for patients requiring authorizations. This role performs telephonic and concurrent reviews of inpatient hospitalizations and extended outpatient services. The UM Coordinator plays a key role in overturning denials and reviewing reimbursement eligibility for services rendered. They apply healthcare knowledge, utilization management expertise, product benefit understanding, regulatory awareness, and nationally recognized criteria to assess medical necessity.
Essential Duties and Responsibilities:
- Reviews clinical documentation to ensure compliance with payer-specific medical necessity requirements and coding standards. Provides education and guidance to physicians on documentation best practices to support accurate coding and optimal reimbursement.
- Applies nationally recognized criteria (e.g., InterQual, MCG) to validate medical necessity for inpatient and outpatient services.
- Prepares, drafts, and submits clinical documentation to payers to support authorization requests, including pre-admission approvals, extensions for additional days of stay, and appeals to overturn payment denials.
- Ensures maximum appropriate payer reimbursement for all services and supplies provided to patients by the hospital.
- Collaborates with other coding professionals and services to ensure accurate CPT, ICD-10, and DRG assignment for reimbursement optimization.
- Drafts and submits detailed appeals for denied claims, including clinical justification and supporting documentation.
- Assists and facilitates the physician peer-to-peer review process with payers.
- Provides consultation to medical and nursing staff, RN Care Coordinator, Health Information Management (HIM), and revenue cycle personnel on potential issues with reimbursement.
- Works closely with the RN Care Coordinator to support discharge planning activities.
- Tracks and analyzes denial reasons to identify systemic issues and recommend process improvements. Assists in aggregating data for quality trending. Participates in process improvement initiatives as required.
- Prepares documentation and supports audit activities related to utilization review and reimbursement. Assists in responding to audit findings and implementing corrective action plans.
- Adheres to best practices, including CMS guidelines, CIHQ standards, and state laws governing medical necessity and Case Management Standards.
- Participates in UR Committee.
- Performs other duties and special projects as assigned to support departmental and organizational goals.
- Education & Training:
- Associate's degree in healthcare administration, nursing, or related field, required.
- Bachelor's degree in nursing, Healthcare Administration, or Business Administration, preferred.
- Coursework or certification in medical billing, coding, or healthcare compliance, preferred.
- Experience:
- Minimum of 2 years in Utilization Management in an acute care setting, required.
- At least 1 year of experience drafting and submitting reconsiderations and appeals to payers.
- Preferably 2 years of experience using InterQual or Milliman criteria.
- Licensure/Certification/Registration:
- Current Texas LVN or RN license, preferred.
- Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), or Certified Professional Coder (CPC), preferred.
- Orthopedic coding certification preferred (e.g., COSC).
- Key Skills:
- Strong knowledge of CPT, ICD-10-CM, ICD-10-PCS, HCPCS, and DRG grouping systems.
- Proficiency in EHR and billing systems (CPSI, Epic, Cerner, or similar).
- Excellent written and verbal communication.
- Detail-oriented with strong organizational and analytical abilities.
- Understanding of payer medical policies, appeals processes, and revenue cycle management.
We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by applicable law.
Similar jobs
Hillwood Investment Properties (HIP) seeks an Asset Management Coordinator to join its growing team in Dallas, Texas. · ...
1 week ago
+Job summary · Hillwood Investment Properties is seeking an Asset Management Coordinator to join our growing team in Dallas, Texas. · +ResponsibilitiesCoordinate the transition of newly acquired or developed assets from Acquisitions and Development to Market Leadership and Proper ...
4 weeks ago
The Operations Coordinator/Manager supports the efficient delivery of geospatial services by tracking utilization and performance metrics · coordinating resources and improving operational processes.This role partners with project managers the HR coordinator and CEO to provide d ...
3 weeks ago
Hillwood Investment Properties is seeking an Asset Management Coordinator to join our growing team in Dallas, Texas. · ...
4 weeks ago
The Utilization Management Coordinator supports Insurance Verification (IV) by securing pre-certification for patients requiring authorizations. · ...
4 days ago
We are seeking a Manager of Tenant Coordination (MTC) to join our regional office located in Dallas, Texas.The overall purpose of this role is to guide new tenants through every phase from lease execution to store opening. · In this role, you will ensure that all projects align w ...
2 weeks ago
We are hiring a Cash Management Coordinator to join our team. The successful candidate will be responsible for responding to accounting and property personnel requests, implementing treasury workstation, processing payments, and verifying information. · ...
1 month ago
We create places people want to call home — starting with you. · We're currently hiring for a Cash Management Coordinator — someone who brings fresh thinking, follows through, and knows how to bring people together to get results. · ...
1 week ago
We are looking for a full time Wealth Management Client Services & Operations Coordinator. · ...
2 weeks ago
Mission of Austin Street Center: · Founded in 1983, Austin Street Center provides emergency shelter and meets the basic need of the most vulnerable people experiencing homelessness in Dallas. · Core Values: · Kindness, Trustworthiness, Empowerment, Determination · Position Purpos ...
12 minutes ago
Avant Specialty Benefits is seeking a detail‑oriented, service‑driven Centralized Leave Management Coordinator to support one of our dedicated clients in navigating the complexities of employee leave. · Coordinate FMLA and disability programs. · ...
1 week ago
Avant Specialty Benefits is seeking a detail-oriented service-driven Centralized Leave Management Coordinator to support one of our dedicated clients in navigating the complexities of employee leave. · ...
3 weeks ago
We are looking for a full time Wealth Management Client Services & Operations Coordinator who supports financial advisors by managing client service account administration day-to-day operational needs within a wealth management or private banking environment. · ...
2 weeks ago
Hillwood Investment Properties (HIP) is seeking an Asset Management Coordinator to join our growing team in Dallas Texas This role serves as a central coordination point across markets supporting alignment accountability and disciplined execution of asset-level strategy across th ...
4 weeks ago
Austin Street Center provides emergency shelter and meets the basic need of people experiencing homelessness in Dallas.We are looking for a smart problem-solver with exceptional customer service skills who can engage and motivate people who often suffer from various physical, men ...
4 weeks ago
The Care Coordinator will establish and maintain an efficient care management process by determining patient financial and medical eligibility, medical necessity, and developing individual patient plans of care. · Responsible for maintaining knowledge of utilization review, care ...
1 month ago
A Centralized Leave Management Coordinator is needed to support a client with leave of absence processes. The role requires knowledge of FMLA and state-specific leave laws. · ...
3 weeks ago
The Care Coordinator will establish and maintain an efficient care management process by determining patient financial and medical eligibility. · Plans and develops specific objectives, goals and actions designed to meet the patient's needs as identified through the assessment pr ...
1 month ago
The International Rescue Committee responds to the world's worst humanitarian crises helping to restore health safety education economic wellbeing and power to people devastated by conflict and disaster. · ...
1 month ago
+The Intensive Case Management (ICM) Coordinator leads a team of ICM caseworkers to address barriers to safety and wellness for especially vulnerable refugees, asylees, and other ORR-eligible populations. · +Assist clients in navigating healthcare and social service systemsDevelo ...
1 week ago