Lead Utilization Management Coordinator

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The Lead Utilization Management Coordinator (UMC) assists in driving the strategic oversight, execution, and mitigation of concurrent denials to secure timely authorizations, prevent costly and lengthy appeals, and optimize institutional reimbursement. This role functions as an advanced clinical and operational leader with acute knowledge of utilization management (UM), medical necessity, patient status determination, payor behaviors, and complex appeal strategies. Serving as an SME for operational integrity, the Lead UMC assists in quality assurance frameworks and continuous monitoring protocols to track team performance and compliance. Serving as a crucial bridge across the revenue cycle and clinical care, the Lead UMC mentors the utilization management coordinators. They partner closely with the Physician Advisor team and Clinical Appeals to participate in process improvements as an SME for the UMC role. The Lead UMC also works towards proactive denial-prevention solutions and high-impact educational initiatives for staff.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC).

EXPERIENCE:

1. Four (4) years clinical experience in a hospital setting.

2. FIVE (5) years Utilization Review and/or Clinical Appeals and/or case management experience.

PREFERRE QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s Degree in Nursing.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. COACHING AND MENTORING: ASSIST IN DEVELOPING TEAM MEMBERS SKILLS AND ACTIVE IDENTIFICATION OF WEAKNESSES THROUGH:

a. Observation of daily workflows and perform skill gap analyses.

b. Provide real-time feedback – address errors immediately with corrective feedback.

c. Track action items on weekly meeting grid.

2. ASSISTING AND MONITORING DAY-TO-DAY OPERATIONS:

a. Assure that daily deadlines are met.

b. Review of staffing to ensure adequacy (vacation / holiday coverage).

3. REPORTING; ACTING AS A LIASON BETWEEN THE TEAM AND LEADERSHIP:

a. Performance Improvement - reporting opportunities for improvement identified in the day-to-day processes.

b. Quality Assurance - reporting any backslide in standard operating procedures.

c. KPI tracking – reporting team output against established goals.

4. ACTING AS A SUBJECT MATTER EXPERT:

a. Act as the daily point person for staff questions and concerns.

b. Oversight over orientation of new staff members.

c. Assist with educational needs and new process initiatives.

d. Assist in document control – yearly review of staff resources / documents / process flows.

5. Assess all referred concurrent denials to determine appropriate next steps including, but not limited to, requesting peer to peer, determining need to change billing status, requesting additional clinical information from the Utilization Review RNs, and referring cases to the Clinical Appeals team.

6. Reviews medical record documentation and provides recommendations for denial management based on clinical expertise and payor behaviors.

7. Partners with leadership and contracting to develop most beneficial language for payor agreements and contracts.

8. Collaborates with internal and external physician advisor functions by coordinating and facilitating peer to peer assignments.

9. Collaborates with UR coordinators, clinical appeals, and physician advisors to prevent and manage concurrent denials.

10. Advocates for the patient and hospital with insurance companies to optimize reimbursement and hospital stay coverage.

11. Manages all assigned processes in compliance with the Medicare Conditions of Participation including, but not limited to the W2/121 billing/self-denial process, patient communication regarding UR committee determinations, and communication with external entities as required in the federal and state regulations.

12. Analyzes key metrics for projects as assigned.

13. Maintains working knowledge of payor requirements.

14. Partner with Clinical Appeals team to ensure aligned process for front and back end denial management.

15. Provide highly effective reconsideration clinicals to payors in order to prevent denials.

16. Facilitates professional communication to ensure the authorization process is completed in a patient centered manner with adherence to quality and timeline standards.

17. Maintains effective and efficient processes for determining appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers.

18. Maintains knowledge and understanding of applicable federal regulations and Conditions of Participation.

19. Actively participates in process improvement initiatives, working with a variety of departments and multidisciplinary staff.

20. Effectively and efficiently manages a diverse workload in a fast-paced, rapidly changing regulatory environment.

21. Collaborates with other members of the interdisciplinary team as outlined in the system UM Plan

22. Coordinates communication with physicians and collaborates to ensure appropriate patient status.

23. This individual identifies, develops, and provides orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis.

24. Consistently demonstrate ability to serve as a role model and change agent by promoting the concept of teamwork and the revenue cycle process continuum of high performing teams.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Office work which includes sitting for extended periods of time.

2. Must have reading and comprehension ability.

3. Visual acuity must be within normal range.

4. Must be able to communicate effectively.

5. Must have manual dexterity to operate keyboards, fax machines, telephones and other business equipment.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Office work which includes sitting for extended periods of time.

2. Maintains confidential home office space.

3. Required weekends and holidays as assigned.

SKILLS & ABILILTIES:

1. Effective verbal and written communication skills.

2. Strong interpersonal skills.

3. Strong attention to detail.

4. Knowledge of medical terminology required.

5. Knowledge of third party payers required.

6. Ability to use tact and diplomacy in dealing with others.

7. Working knowledge of computers.

8. Excellent customer service and telephone etiquette.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

SYSTEM West Virginia University Health System

Cost Center:

553 SYSTEM Utilization Review