Utilization Review Coordinator Job Billings area,Montana USA,Healthcare

Description

JOB SUMMARY:

Manages the administrative components of utilization review for all levels of care and all payers. Serves as the organization's central point of accountability for authorization tracking, assuring that prior authorizations, continued stay reviews, requests for information, reconsiderations, and retrospective reviews are complete and submitted within required time frames. This is a non-clinical position: the UR Coordinator does not determine medical necessity or author clinical content, but requests clinical documentation from clinical staff according to the department's provider priority list, assembles and reviews submission packets for completeness, submits them, and tracks each authorization from admission through discharge and billing.

Partners with the business office on authorization-related denials and unauthorized days, and with clinical leadership on clinical input and appeals. Assures adherence to Montana Medicaid and BHDD utilization management requirements, payer-specific requirements, and federal regulations including HIPAA and 42 CFR Part
2. Positively represents the organization and promotes Rimrock's Mission to the community.

ESSENTIAL FUNCTIONS:

Maintains the UR tracker as the single record of every authorization across Medicaid and commercial payers, including authorized dates, units, next deadlines, assigned clinical staff, status, and outcomes.

Monitors authorization end dates and calendars all required deadlines, including continued stay submission windows, request for information responses, peer-to-peer and desk review requests, and retrospective review windows.

Verifies payer eligibility and authorization requirements at admission in partnership with admissions and billing.

Requests clinical documentation from clinical staff with clear due dates, assigning each request according to the department's provider priority list, which ranks available clinical staff by credential level appropriate to the request and current availability.

Follows up on outstanding clinical documentation requests; reassigns to the next available provider on the priority list and escalates unresolved requests to the Assistant Controller and the Director of Clinical Services.

Schedules peer-to-peer reviews between payer reviewers and the appropriate Rimrock clinician or physician.

Assembles authorization and continued stay packets from the electronic health record and reviews them for completeness against payer requirements; does not create clinical content or determine medical necessity.

Submits authorization requests through payer portals, including the Montana Medicaid utilization review contractor portal, and by fax and telephone within required time frames.

Assures that documentation supporting auto‑authorized services is submitted within the timeframe required by the payer.

Logs determinations, requests for information, and denials; routes requests for information to the author of the original documentation and submits responses within required time frames.

Prepares and files written requests for reconsideration, including peer-to-peer and desk reviews, and tracks each to resolution.

At discharge, reconciles final authorized dates with actual dates of service, closes the case with the payer or review contractor, and notifies billing of any unauthorized days before claims are submitted.

Works authorization‑related denials with the accounts receivable team, identifies root causes, and recommends process corrections.

Submits retrospective review requests when patients become Medicaid eligible after admission.

Maintains written payer requirements, contacts, templates, and desk procedures; cross‑trains a designated backup.

Monitors BHDD Medicaid provider manual updates and payer…