Psychiatric Utilization Review Coordinator
Insight Health Systems, Chicago, IL, United States
Position Summary
The Psychiatric Utilization Review (UR) Coordinator is responsible for conducting concurrent reviews for psychiatric patients to ensure medical necessity and continued stay appropriateness. This role serves as a liaison between clinical teams and third‑party payers, providing real‑time information on authorization status, last covered days, and upcoming review deadlines. The UR Coordinator ensures timely response to calls and faxes, accurate documentation in required systems, and proper escalation of denials to the appeals team.
These duties are to be performed in a highly confidential manner, in accordance with the mission, values and behaviors of Insight Hospital and Medical Center. Employees are further expected to provide a high quality of care, service, and kindness toward all patients, staff, physicians, volunteers and guests.
Key Responsibilities
Utilization Review & Concurrent Reviews
Conducts concurrent reviews for all active psychiatric patients to determine continued stay medical necessity
Completes continued stay reviews within required timeframes based on payer requirements and internal deadlines
Assesses clinical documentation to support ongoing authorization
Communicates review outcomes and next steps to treatment teams as appropriate
Payer Communication & Authorization Tracking
Initiates and maintains contact with insurance payers to obtain and verify continued stay authorization
Documents all payer communications and authorization decisions in appropriate systems.
Tracks active patient authorizations, last covered days, and next review due dates
Provides updated authorization information to clinical teams during rounds and as needed
Rounds Participation
Attends and actively participates in daily or weekly clinical rounds
Provides real‑time updates on each patient's authorization status, including:
Last covered day
Next review due date
Any pending payer actions or concerns
Notes any changes in patient status that may impact length of stay or authorization
Denials Management
Receives and reviews denial notices from payers
Provides denial letters and supporting documentation to the Appeals Team or UR Supervisor for further action
Updates supervisor on denial particulars as directed
Tracks denial patterns and reports trends to supervisor
Time‑Sensitive Communication
Monitors and responds to incoming calls from payers, providers, and internal departments in a timely manner
Processes incoming faxes related to authorizations, denials, and clinical documentation throughout the day
Ensures no voicemail or fax goes unaddressed beyond 24 hours
Escalates urgent or complex issues to supervisor immediately
Documentation & Data Management
Maintains timely and accurate records of all utilization review activities
Documents all reviews and actions in required systems
Ensures that notes are complete, clear, and reflect actions taken and what is pending by the end of the shift
Assists with data collection as requested by supervisor
Support & Collaboration
Collaborates with Pre‑Cert Specialists to ensure smooth handoff between initial certification and concurrent review
Communicates authorization updates to crisis team, social workers, and providers
Participates in team meetings and contributes to process improvement discussions
Compliance & Regulatory Knowledge
Maintains knowledge of medical necessity criteria for psychiatric continued stay reviews
Understands requirements for Medicare, Medicaid, managed care, and commercial insurance coverage
Ensures compliance with HIPAA regulations and maintains confidentiality of patient information
Demonstrates knowledge of inpatient psychiatric treatment and documentation requirements
Qualifications
Education Requirements
Bachelor's degree in healthcare administration, Psychology, Social Work, or related field; RN preferred
Relevant experience may be considered in lieu of degree
Experience
Minimum 1‑2 years of experience in utilization review, healthcare administration, or related role required
Experience working with psychiatric or behavioral health populations strongly preferred
Familiarity with Medicare, Medicaid, and commercial insurance requirements preferred
Experience with InterQual/MCG criteria preferred
Knowledge, Skills & Abilities
Knowledge
Working knowledge of medical necessity criteria for psychiatric continued stays
Understanding of insurance authorization processes and terminology
Familiarity with psychiatric diagnoses, DSM‑5, and levels of care
Knowledge of HIPAA and confidentiality requirements
Skills
Strong organizational skills and attention to detail
Excellent verbal and written communication skills for interacting with payers and clinical teams
Ability to prioritize multiple tasks and respond to time‑sensitive requests
Proficiency with electronic medical records (Cerner preferred) and Microsoft Office (Outlook, Excel, Word)
Critical thinking and problem‑solving abilities
Ability to track and trend denial patterns
Abilities
Ability to work independently and manage own caseload
Capacity to remain focused despite frequent interruptions (calls, emails, faxes)
Ability to participate effectively in rounds and communicate clearly with clinical staff
Flexibility to adapt to changing priorities and payer requirements
Commitment to accuracy and thorough documentation
Ability to elevate appropriately when stuck or uncertain
Working Conditions
Full‑time position, Monday‑Friday, with potential for occasional extended hours based on patient needs
Work is performed in an office setting within a hospital environment
May require sitting for extended periods while completing computer‑based tasks
Frequent telephone and computer use
Regular participation in clinical rounds
Benefits
Paid Sick Time – effective 90 days after employment
Paid Vacation Time – effective 90 days after employment
Health, vision & dental benefits – eligible at 30 days, following the 1st of the following month
Short and long‑term disability and basic life insurance – after 30 days of employment
Insight Employees are required to be vaccinated for COVID‑19 as a condition of employment, subject to accommodation for medical or sincerely held religious beliefs.
Insight is an equal opportunity employer and values workplace diversity!
#J-18808-Ljbffr
The Psychiatric Utilization Review (UR) Coordinator is responsible for conducting concurrent reviews for psychiatric patients to ensure medical necessity and continued stay appropriateness. This role serves as a liaison between clinical teams and third‑party payers, providing real‑time information on authorization status, last covered days, and upcoming review deadlines. The UR Coordinator ensures timely response to calls and faxes, accurate documentation in required systems, and proper escalation of denials to the appeals team.
These duties are to be performed in a highly confidential manner, in accordance with the mission, values and behaviors of Insight Hospital and Medical Center. Employees are further expected to provide a high quality of care, service, and kindness toward all patients, staff, physicians, volunteers and guests.
Key Responsibilities
Utilization Review & Concurrent Reviews
Conducts concurrent reviews for all active psychiatric patients to determine continued stay medical necessity
Completes continued stay reviews within required timeframes based on payer requirements and internal deadlines
Assesses clinical documentation to support ongoing authorization
Communicates review outcomes and next steps to treatment teams as appropriate
Payer Communication & Authorization Tracking
Initiates and maintains contact with insurance payers to obtain and verify continued stay authorization
Documents all payer communications and authorization decisions in appropriate systems.
Tracks active patient authorizations, last covered days, and next review due dates
Provides updated authorization information to clinical teams during rounds and as needed
Rounds Participation
Attends and actively participates in daily or weekly clinical rounds
Provides real‑time updates on each patient's authorization status, including:
Last covered day
Next review due date
Any pending payer actions or concerns
Notes any changes in patient status that may impact length of stay or authorization
Denials Management
Receives and reviews denial notices from payers
Provides denial letters and supporting documentation to the Appeals Team or UR Supervisor for further action
Updates supervisor on denial particulars as directed
Tracks denial patterns and reports trends to supervisor
Time‑Sensitive Communication
Monitors and responds to incoming calls from payers, providers, and internal departments in a timely manner
Processes incoming faxes related to authorizations, denials, and clinical documentation throughout the day
Ensures no voicemail or fax goes unaddressed beyond 24 hours
Escalates urgent or complex issues to supervisor immediately
Documentation & Data Management
Maintains timely and accurate records of all utilization review activities
Documents all reviews and actions in required systems
Ensures that notes are complete, clear, and reflect actions taken and what is pending by the end of the shift
Assists with data collection as requested by supervisor
Support & Collaboration
Collaborates with Pre‑Cert Specialists to ensure smooth handoff between initial certification and concurrent review
Communicates authorization updates to crisis team, social workers, and providers
Participates in team meetings and contributes to process improvement discussions
Compliance & Regulatory Knowledge
Maintains knowledge of medical necessity criteria for psychiatric continued stay reviews
Understands requirements for Medicare, Medicaid, managed care, and commercial insurance coverage
Ensures compliance with HIPAA regulations and maintains confidentiality of patient information
Demonstrates knowledge of inpatient psychiatric treatment and documentation requirements
Qualifications
Education Requirements
Bachelor's degree in healthcare administration, Psychology, Social Work, or related field; RN preferred
Relevant experience may be considered in lieu of degree
Experience
Minimum 1‑2 years of experience in utilization review, healthcare administration, or related role required
Experience working with psychiatric or behavioral health populations strongly preferred
Familiarity with Medicare, Medicaid, and commercial insurance requirements preferred
Experience with InterQual/MCG criteria preferred
Knowledge, Skills & Abilities
Knowledge
Working knowledge of medical necessity criteria for psychiatric continued stays
Understanding of insurance authorization processes and terminology
Familiarity with psychiatric diagnoses, DSM‑5, and levels of care
Knowledge of HIPAA and confidentiality requirements
Skills
Strong organizational skills and attention to detail
Excellent verbal and written communication skills for interacting with payers and clinical teams
Ability to prioritize multiple tasks and respond to time‑sensitive requests
Proficiency with electronic medical records (Cerner preferred) and Microsoft Office (Outlook, Excel, Word)
Critical thinking and problem‑solving abilities
Ability to track and trend denial patterns
Abilities
Ability to work independently and manage own caseload
Capacity to remain focused despite frequent interruptions (calls, emails, faxes)
Ability to participate effectively in rounds and communicate clearly with clinical staff
Flexibility to adapt to changing priorities and payer requirements
Commitment to accuracy and thorough documentation
Ability to elevate appropriately when stuck or uncertain
Working Conditions
Full‑time position, Monday‑Friday, with potential for occasional extended hours based on patient needs
Work is performed in an office setting within a hospital environment
May require sitting for extended periods while completing computer‑based tasks
Frequent telephone and computer use
Regular participation in clinical rounds
Benefits
Paid Sick Time – effective 90 days after employment
Paid Vacation Time – effective 90 days after employment
Health, vision & dental benefits – eligible at 30 days, following the 1st of the following month
Short and long‑term disability and basic life insurance – after 30 days of employment
Insight Employees are required to be vaccinated for COVID‑19 as a condition of employment, subject to accommodation for medical or sincerely held religious beliefs.
Insight is an equal opportunity employer and values workplace diversity!
#J-18808-Ljbffr