Utilization Review Coordinator

Description:The Utilization Review Referral Coordinator is responsible for answering phone calls and responding to faxed requests from providers for services that require prior authorization. The Utilization Review Referral Coordinator reviews requests for medical necessity using evidence-based criteria or internal guidelines while maintaining compliance with departmental and federal regulations. Responsible for using evidence-based criteria to review for prior authorization of outpatient and inpatient services for commercial and Medicare product lines. Coordinate authorizations, including specialist referrals, surgery, outpatient therapies, DME, both internally and externally, in accordance with departmental guidelines and federal regulations. Ensure services authorized are covered benefits and are medically necessary, citing criteria or certificates of coverage/evidence of coverage used to make determinations. Forward potential denials to the Medical Director or designee; forward any other services requiring administrative review to the proper designee. Ensure all reviews that require full clinical oversight are forwarded to a nurse for review prior to approval. Regularly review pending authorizations to ensure timely completion or request extension for final decision date, if needed. Receive incoming and make outgoing phone calls to providers and physicians. Notify providers and physicians of approval and denials in accordance with departmental guidelines. Identify provider network and/or utilization issues and refer to supervisor for resolution. Interact with internal and external customers to ensure that everyone receives quality customer service. Meet minimum standards as set for the department.Skills:precertification, insurance, Medicare, nurse, surgery, DME, referral, NORMANTop Skills Details:precertification, insurance, Medicare, nurse, surgery, DME, referral, NORMANAdditional Skills & Qualifications:Basic knowledge of medical terminology. Ability to research, read, and interpret health plan or governmental contracts, and medical policy guidelines. Ability to work under pressure to meet deadlines with minimal supervision. Basic computer and data entry skills. Demonstrate excellent customer service skills through written and verbal communication. Ability to work independently and as a member of the team. Demonstrate strong organizational and time management skills.Ability to use 2 computer screens and toggle between 4 programs at a time. Ability to type and talk on the phone at the same time. Must have strong critical thinking skills.Experience Level:Expert LevelAbout Actalent: Actalent connects passion with purpose. Our scalable talent solutions and services capabilities drive value and results and provide the expertise to help our customers achieve more. Every day, our experts around the globe are making an impact. We’re supporting critical initiatives in engineering and sciences that advance how companies serve the world. Actalent promotes consultant care and engagement through experiences that enable continuous development. Our people are the difference. Actalent is an operating company of Allegis Group, the global leader in talent solutions.The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.