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Utilization Review Coordinator

Baptist Health Care
United States, Florida, Pensacola
Feb 21, 2025
Job Description The Utilization Review Coordinator provides support to the utilization and case review process. The coordinator works collaboratively with all team members of Utilization Review (UR), Case Management (CM), and Clinical Documentation Improvement (CDI) programs. This role works with other hospital departments such as Hospitalist/Providers, Access Coordinators and Inpatient Verification. The coordinator assists the UR and CDI teams to ensure patient's admit status, payer authorizations, and clinical criteria and documentation reviews are completed and communicated to all appropriate stakeholders. The position enters relevant information into UR/CDI databases, generates reports, and maintains accurate records related to UR and CDI processes, and effectively communicates with both internal staff and external stakeholders (such as, insurance companies). The role provides overall administrative support regarding clinical and payer coordination and timeliness as well as data entry, reporting, maintaining records and other clerical organizational office duties. The position is physically located at Baptist Hospital but can have some responsibilities at other Baptist facilities. Responsibilities Communicates with internal stakeholders regarding patient status/changes, payer authorization requests, approvals and denials. Manages payer communications concerning case statuses, authorizations, and denials to ensure UR team is meeting requested timelines for clinical information and appeals. Develops and sustains excellent relationships and communications with our Providers/office personnel, surgery schedulers, billing/revenue teams, CM, and Payer representatives. In collaboration with UR/CDI, prioritizes and follows up on case status changes and case denials as it may impact for medical necessity and patient discharge planning. Assists CDI with ensuring case query/clarification regarding documentation diagnosis and severity illness/risk of mortality are addressed per program timelines. Collaborates with information technology team on Careport updates and daily auto census updates. Assimilates the collection, organization, and analysis of data related to utilization reviews, ensuring accuracy and confidentiality. Performs various administrative duties such as answering phones, managing emails and faxes, preparing reports and handling invoice management. Provides daily census summaries, and maintains Provider and Payer contact spreadsheet. Updates patient accounts for clinical reviews and authorization communication. Assists UR Denial Nurse and program as needed. Assist in other duties as assigned to support the operational needs of the department and organization. May be required to remain on campus immediately before, during, and after severe weather and/or disasters. Qualifications 2 years customer service experience required Previous registration and/or scheduling experience preferred Experience as a financial counselor, customer service representative, registrar, or scheduler preferred Relevant revenue cycle experience preferred About Us Baptist Health Care is a not-for-profit health care system committed to improving the quality of life for people and communities in northwest Florida and south Alabama. The organization includes three hospitals, four medical parks, Andrews Institute for Orthopaedic & Sports Medicine, and an extensive primary and specialty care provider network. With more than 4,000 team members, Baptist Health Care is one of the largest non-governmental employers in northwest Florida. Baptist Health Care, Inc. is an Equal Opportunity Employer. BHC maintains and enforces a policy that prohibits discrimination against any workforce members or applicants for employment because of sex, race, age, color, disability, marital status, national origin, religion, genetic information, or other category protected by federal, state or local law.