Job Description

Location: Rockledge Regional Medical Center
Posted Date: 1/27/2020


The Utilization Review staff assumes primary responsibility of communicating with payors to obtain authorization. Provide clinical information to payor as requested. Document authorization numbers, concurrent denial, attempts to overturn concurrent denials and coordinate Peer-to-Peer communication as needed for all patient hospital stays. Follow-up communication with payors to ensure authorization obtained for patient hospitalization. Communicate appropriately with Care Manager Utilization Nurses and Team Leader regarding authorization status and payor requests.


  • Documents authorization and concurrent denial information in Care Management Documentation system daily.
  • Actively prevent denial by submitting clinical information within 24 hours of admission or as delineate by payor.
  • Communicate continued stay clinical information as requested by payor or as authorization is due.
  • On occasion, may need to send medical records to physician advisor as directed by Utilization RN Team Lead/Supervisor.
  • Document payor concurrent denials of coverage appropriately. Provide additional clinical information as required, communicate and refer to UR RN for additional clinical or Peer-to-Peer discussion.
  • Assist in organizing, scheduling Peer to Peer reviews with payers and/or Corporate Physician Advisor.
  • Communicate with Care Manager Utilization RN regarding status of authorization and Peer-to-Peer per payor requests.
  • Ability to navigate payer website / portals to perform remittance research and gather additional information.
  • Follow-up calls as needed to payors to ensure authorization is obtained for each patient.
  • Knowledge of contracted payers preferred. Maintains current information on insurance requirements according to payor grid
  • Has working knowledge of status requirements for Medicare/Medicaid, managed care and private insurance companies. Interfaces with insurance / review companies to insure appropriate reimbursement.
  • Proactively and professionally contacts insurance companies, government agencies, patients, and other customers via phone, email, or paper correspondences to gather or provide information required for the successful submission and resubmission of claims.
  • Aggressively utilizes full range of information and tools available on insurance and third-party websites to gather required information
  • Documents all correspondence and conversations with insurance companies, government agencies, patients, and other customers on patient's account as appropriate
  • Collaborates within a problem solving-framework with all stakeholders in the denial’s resolution workflows.
  • On occasion, may need to send medical records to physician advisor as directed by Utilization RN Team Lead/Supervisor.
  • Forwards denials to appropriate electronic records work queues for coding, case management, or other functional expertise where required
  • Maintains and efficient office environment
  • Performs other duties as requested.


  • Good organizational skills
  • Ability to assist in development and process improvement in obtaining payor authorizations and concurrent denial appeals.
  • Manages time effectively, sets priorities, and consistently meets deadlines
  • Excellent verbal, written, telephonic and communication skills.
  • Attention to detail regarding documentation and follow-up to ensure process completed timely.
  • Ability to effectively interact with insurance companies
  • Effectively interact with all levels of the organization and maintain cooperative relations with internal and external customers
  • Demonstrates initiative and proactive approach to problem resolution.
  • Performs well independently and on a team.
  • Assumes accountability for demonstrating behaviors consistent with the customer service policy.
  • Works competently with computer-based charting and other clinical and non-clinical software programs.
  • Readily adapts to change.
  • Understands Medicare and Medicaid coverage details.
  • Operates office equipment efficiently
  • Critical thinking skills required
  • Utilizes independent judgment and discretion in the UR coordinator role.
  • Identifies denial patterns and works with Utilization Review RN Team Lead/ Supervisor to positively impact outcomes
  • Ability to document predenials data on UR / Denial worksheet and scan into electronic Medical Record
  • Perform other duties as needed and required


Minimum Education/ Experience:

  • Minimum High School graduate or GED Equivalent.
  • Two to four years’ experience in healthcare preferred
  • Ability to read and communicate efficiently in English required
  • Basic computer knowledge required, (Word, Excel, Microsoft Office, Meditech)

Minimum skills/abilities:

  • Takes opportunity to know and learn other roles and processes and works together to assist with process improvement initiatives.
  • Stays informed and communicates goals, identified issues, and proposed solutions to work unit management.
  • Builds trust with peers by getting to know them and modeling a respectful work place. (i.e., listening to their ideas). Promotes an atmosphere where candid and open discussions take place to include positively reinforcing peer efforts.
  • Support work unit goals and objectives by interacting, communicating, and collaborating with team members in order to maximize group effectiveness.
  • Is open and honest with peers and supports communication of events and institutional messages in a timely manner.

Application Instructions

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