Utilization Review Coordinator

Bachelor's degree in Social Work, Nursing, or any related field.

Clinical or UR experience in PHP or IOP levels of care.

1-2 years of experience in the healthcare industry in utilization review or clinical care.

Expert understanding of patient documentation, chart auditing, and state and federal regulations.

Proficient in MS Office applications and ability to learn department and job-specific software systems (e.g., applicable practice management and EMR systems)

Demonstrate organizational skills.

$50,000

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$55,000 USD

& Perks

At Guidelight, we value a work-life integration culture. This approach allows our teammates to focus on what matters most to them, while also caring for our clients and fellow teammates. We have found that this promotes a sustainable and successful culture, and we offer the following benefits to our teammates to demonstrate this commitment to each other.

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.