Utilization Review Coordinator

Title: Utilization Review Coordinator

Reports to: Director of Revenue Cycle Management 

Department/Location: Remote, but only considering candidates in PST.

FLSA Status: Exempt

Travel Requirement: None

Summary: 

Reporting directly to the Director of Revenue Cycle Management, this team member plays an essential role in helping clients access and continue the care they need. They will be responsible for handling pre-certifications, authorizations, retro-authorizations, appeals, medical records requests, and chart auditing duties that support accurate reporting of each client's clinical level of care, program participation, and treatment days utilized. As a subject matter expert on payor requirements and expectations, particularly across the WA and CA markets, this individual will partner closely with clinical and revenue cycle teams to remove administrative barriers, optimize utilization review outcomes, and support Guidelight's mission of delivering accessible, high-quality behavioral healthcare.

Responsibilities: 

• Utilization Review on Behalf of the Clinics:
  • Prescreen referrals to project/anticipate authorizations. Provide recommendations regarding level of care/services and treatment planning.
  • Conduct live reviews with payors and level of care chart reviews, conceptualizing the clinical presentation and care needs and applying medical necessity guidelines and /or LOCUS to compel authorization.
  • Clinically negotiate authorization outcomes with the payor, collaborating in advance with the primary treating clinicians.
  • Coordinate Peer-to-Peer (P2P) Review preparation and assist with scheduling. Provide guidance and training to clinicians on completing P2P reviews.
  • Establish internal authorization or denial determinations for No Authorization Required (NAR) requests.
  • Establish post denial appeal response recommendations.
  • Obtain portal access to any utilization review portals for an efficient and scalable process.
• Interdepartmental Relations and Communication:
  • Coordinate with the clinical team on requests with clinically weaker presentations.
  • Coordinate all concurrent insurance reviews with clinicians and medical team.
  • Provide guidance on specific interventions or areas on which to focus to result in maximum authorized days.
  • Provide ongoing feedback and recommendations for improvement to meet payor medical necessity guidelines.
  • Attend and participate in daily huddles/weekly rounds as the payor expert to ensure appropriate authorization outcomes and provide ongoing education regarding payor requirements.
  • Communicate with relevant parties at the facility and in RCM about any issues with coverage or denials, facilitating client notifications as needed.
  • Partner with intake, utilization review, and finance for best practices in overarching company goals related to RCM.
  • Timely completion of the Denial Notification process.
•  Accurate Data Entry:
  • Document deficiencies for identification on the daily reporting
  • Timely documentation of authorization in KIPU/Avea
  • Upload authorization letters to KIPU/Avea UR module.
•  Clinical Auditing:
  • Notify the primary therapist of any missing documentation or delinquent services
  • Review medical records for quality clinical documentation and compliance with licensing, accrediting, and payor requirements
  • Running daily reports to ensure that all information needed for timely review has been entered into the EMR and communicating with the clinic team members to correct or update any missing or incorrect documentation.
•  Policy Compliance:
  • Ensuring compliance with legal, regulatory, and policy requirements.
•  Process Improvement:
  • Identifying Clinical problems and proposing innovative solutions.
•  Additional job duties as assigned.

Qualifications:

• Bachelor's degree in Social Work, Nursing, or any related field.
• Must be based in PST, with an understanding of the west coast Payer landscape, specifically CA or WA.
• 2-3+ years of UR experience in behavioral health, ideally across PHP or IOP levels of care.
• Knowledge of medical necessity criteria, payer authorization processes, documentation standards, and regulatory requirements.
• Proficient in MS Office applications and ability to learn department and job-specific software systems (e.g., applicable practice management and EMR systems)
• Strong organizational, communication, analytical, and problem-solving skills with exceptional attention to detail.