Utilization Review Coordinator

The Inpatient Behavioral Health Social Worker in Utilization Review is responsible for evaluating the medical necessity, appropriateness, and efficiency of behavioral health services provided to patients in an inpatient setting. This role ensures compliance with regulatory standards and payer requirements while supporting optimal patient care and resource utilization. The role integrates and coordinates utilization management and denial prevention by focusing on identifying and removing unnecessary and redundant care, promoting clinical best practice, and ensuring all patients receive “the right care, at the right time, and in the right setting”.

• Conduct utilization reviews for inpatient behavioral health admissions, concurrent stays, and discharge planning.
• Apply clinical criteria (e.g., Inter Qual, Milliman) to assess medical necessity and level of care.
• Collaborate with physicians, nurses, and treatment teams to ensure appropriate care delivery.
• Demonstrate thorough knowledge in the application of behavioral health criteria.
• Communicate with insurance providers to obtain authorizations and manage denials or appeals.
• Communicate payor criteria and issues on a case-by-case basis with multidisciplinary team and follow up to resolve problems with payors as needed; initiate peer to peer when appropriate.
• Contact the attending physician for additional information if the patient does not meet the appropriate medical necessity criteria or in accordance with CMS rules and regulations for continued stay.
• Support multi-disciplinary strategies to reduce length of stay, reduce resource consumption, and achieve positive patient outcomes.
• Maintain accurate documentation of reviews, authorizations, and clinical decisions.
• Monitor patient progress and recommend transitions to lower levels of care when appropriate.
• Participate in interdisciplinary team meetings and contribute to care coordination.
• Ensure compliance with HIPAA, CMS, and other regulatory guidelines.
• Identify high-risk cases and elevate concerns to clinical leadership as needed.
• Support quality improvement initiatives related to utilization management.
• Perform all other duties as assigned.

• Master’s degree in Social Work (MSW).
• 2+ years of experience in behavioral health, preferably in inpatient or managed care settings.
• Prior experience in utilization review or case management strongly preferred.
• Familiarity with clinical review tools (Inter Qual, Milliman).
• Strong understanding of behavioral health diagnoses, treatment modalities, and discharge planning.
• Excellent communication, negotiation, and documentation skills.
• Proficiency in electronic health records (EHR) and utilization management software.

• Comprehensive knowledge of the health care reimbursement system.
• Demonstrated skill in creative problem solving, facilitation, collaboration, coordination, and critical thinking.
• Excellent demonstrated oral, written and communication skills.
• Proficiency in the use of work processing and spreadsheet application.
• Working knowledge of healthcare reimbursement and available community resources.
• Must have strong computer skills and the ability to access internet and other programs applicable to Waterbury Hospital procedures.
• Perform automated functions that fall within job responsibility.