Lead Utilization Management Coordinator

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⚔️ Virginia, West Virginia – Remote

⚔️ Virginia – Remote ⛰️ West Virginia – Remote

⏰ Full Time

🟠 Senior

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WVU Medicine

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

WVU Medicine is a comprehensive health system affiliated with West Virginia University, providing medical services through a network of hospitals across West Virginia. The system includes notable facilities such as J. W. Ruby Memorial Hospital, WVU Medicine Children's, and various other regional medical centers. WVU Medicine offers a wide range of healthcare services, including specialized and advanced medical treatments such as robotic heart surgery. It's also involved in medical education, research, and community health initiatives, emphasizing a mission of delivering high-quality care to the communities it serves.

📋 Description

• Drive strategic oversight, execution, and mitigation of concurrent denials to secure timely authorizations, prevent appeals, and optimize institutional reimbursement • Serve as an advanced clinical and operational leader in utilization management, medical necessity, patient status determination, payor behaviors, and complex appeal strategies • Assist with quality assurance frameworks and continuous monitoring protocols for team performance and compliance • Mentor utilization management coordinators and partner with Physician Advisor and Clinical Appeals teams on process improvements • Develop denial-prevention solutions and educational initiatives • Coach and mentor team members through workflow observation, skill-gap analysis, real-time feedback, and action-item tracking • Monitor day-to-day operations, deadlines, and staffing coverage • Report performance improvement opportunities, quality assurance issues, and KPI results to leadership • Act as subject matter expert and daily point person for staff questions, orientation, education, process initiatives, and document control • Assess concurrent denials and determine next steps, including peer-to-peer requests, billing-status changes, additional clinical information, and Clinical Appeals referrals • Review medical records and recommend denial-management actions based on clinical expertise and payor behaviors • Collaborate with leadership, contracting, physicians, UR coordinators, Clinical Appeals, and interdisciplinary teams • Advocate with insurance companies to optimize reimbursement and hospital-stay coverage • Manage utilization-management processes in compliance with Medicare Conditions of Participation and federal and state regulations • Analyze project metrics and maintain knowledge of payor requirements and applicable regulations • Provide reconsideration clinicals to payors and facilitate patient-centered authorization processes • Determine appropriate admission status based on regulatory and reimbursement requirements • Participate in process improvement initiatives and manage a diverse workload in a fast-paced regulatory environment • Coordinate physician communications to ensure appropriate patient status • Provide ongoing orientation, training, and competency development • Serve as a role model and change agent promoting teamwork and revenue-cycle performance

🎯 Requirements

• Current Registered Nurse license issued by the state in which services will be provided, or current multi-state RN license through the enhanced Nurse Licensure Compact (eNLC) • Four years of clinical experience in a hospital setting • Five years of Utilization Review and/or Clinical Appeals and/or case management experience • Bachelor’s Degree in Nursing preferred • Knowledge of medical terminology • Knowledge of third-party payers • Working knowledge of computers • Effective verbal and written communication skills • Strong interpersonal skills • Strong attention to detail • Ability to use tact and diplomacy • Excellent customer service and telephone etiquette • Ability to read and comprehend • Visual acuity within normal range • Ability to communicate effectively • Manual dexterity to operate keyboards, fax machines, telephones, and other business equipment • Ability to maintain confidential home office space • Ability to work assigned weekends and holidays

🏖️ Benefits

• Remote work arrangement • Confidential home office space • Required weekends and holidays as assigned • Reasonable accommodations may be made for individuals with disabilities