Utilization Review Coordinator

Long Tail Health Solutions is a provider advocate, delivering a suite of technology-enabled services which discover and operationalize payer rules and behaviors to improve the visibility, execution, and outcomes of utilization review, case management, and revenue cycle functions. 

• Required: High school diploma or equivalent; Associate’s degree or certification in a healthcare-related field preferred.

• Preferred: Bachelor’s degree in healthcare administration, nursing, or a related field.

• 2+ years of experience in Utilization Review, case management, or a similar healthcare operations role.

• Knowledge of Utilization Review processes and payer requirements.

• Familiarity with healthcare systems, electronic medical records (EMR), and clinical documentation standards.

• Understanding of healthcare regulations, including Medicare and Medicaid guidelines.

• Strong organizational skills to manage multiple tasks and meet tight deadlines.

• Excellent written and verbal communication skills for professional interactions with clinical staff, payers, and clients.

• Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint) and familiarity with UR-related software.

• Attention to detail to ensure the accuracy of documentation and review submissions.

• Ability to work independently while collaborating effectively within a remote team environment.

• Remote work environment requiring consistent, reliable communication with team members and stakeholders.

• May involve occasional travel for team meetings or client-related events.

The essential functions include, but are not limited to the following:

• Coordination: Manage and track the submission of clinical reviews to payers, ensuring deadlines and requirements are met.

• Payer Communication: Act as the primary liaison with payers to address and resolve any issues related to utilization reviews.

• Documentation: Ensure that clinical documentation and review requests are accurate, complete, and compliant with payer guidelines.

• Team Support: Collaborate with utilization nurses and other team members to ensure seamless operations.

• Compliance: Maintain knowledge of payer guidelines and healthcare regulations to ensure all activities meet compliance standards.

• Process Improvement: Identify and implement opportunities to streamline UR workflows and improve operational efficiency.

• Client Service: Provide exceptional service to clients by addressing inquiries, resolving issues, and ensuring satisfaction with UR operations.