Utilization Review Coordinator

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The UR and RCM Support Coordinator is responsible for securing and maintaining payer authorizations across all levels of care for residential substance use disorder (SUD) treatment, including ASAM Levels 3.5 and 3.7, while also providing cross-functional support to the Revenue Cycle Management department. This role serves as a key link between the clinical team, payers, and the RCM department, ensuring that medical necessity is clearly documented, communicated, and defended throughout each patient's episode of care.

Reporting to the Director of Utilization Review with a dotted-line relationship to the Director of Revenue Cycle Management, the UR and RCM Support Coordinator works in close partnership with billing, denials, appeals, and clinical leadership to drive authorization approval rates, prevent denials at the front end, and protect revenue across the multi-state network of facilities. This is a high-visibility role with direct impact on length of stay, denial rates, and net collections.

• Complete pre-certification, initial, concurrent, and discharge reviews with commercial, Medicaid, and Medicaid managed care payers for residential SUD levels of care (ASAM 3.1, 3.5, 3.7, and detox where applicable).
• Submit clinical information to payers within required time frames, using ASAM criteria and payer-specific medical necessity guidelines to justify admission, continued stay, and level of care.
• Track all authorization requests, approvals, days approved, next review dates, and denials in the UR tracking system; ensure no patient day is at risk due to a missed or expired authorization.
• Escalate authorization issues, denials, or peer-to-peer requests to the Director of Utilization Review and Director of RCM in real time, along with clinical leadership as appropriate.

• Coordinate, prepare, and schedule peer-to-peer reviews between facility physicians and payer medical directors; provide the rendering clinician with a written summary of medical necessity points prior to each call.
• Document peer-to-peer outcomes, including outcome reason, reviewer name, and any payer-specific feedback for use in future submissions.
• Partner with the Director of Utilization Review and Director of RCM, along with the appeals team, to identify trends in concurrent denials and translate findings into documentation and clinical workflow improvements.
• Support the appeals process by providing UR notes, clinical timelines, and the authorization history needed for first- and second-level appeals.

• Review clinical documentation daily for alignment between the billed level of care and the documented level of care; flag and address mismatches before they generate denials (a known driver of pre-payment review and payer recoupment risk).
• Provide real-time coaching and written feedback to clinicians, therapists, and medical providers on documentation elements required to meet ASAM 3.5 and 3.7 medical necessity (e.g., dimensional risk ratings, withdrawal management needs, biomedical and behavioral complications, treatment response, and continued-stay justification).
• Partner with clinical leadership to maintain documentation templates and standards that satisfy commercial payer, state Medicaid, and accreditation requirements across Arkansas, Colorado, Indiana, Kentucky, and Ohio.

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