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Utilization Coordinator
Location
Philippines
Posted
8 days ago
Salary
$5 - $6 / hour
Seniority
Senior
Job Description
Utilization Coordinator
Remote Raven
• Review incoming authorization requests and identify all required clinical documentation for each payer and service type • Submit prior authorization requests to insurance carriers via fax and payer portals within each payer's required timeframe • Ensure all submitted requests are complete, accurate, and include the appropriate supporting clinical documentation to avoid unnecessary delays or denials • Maintain working knowledge of payer-specific authorization requirements, submission methods, and timelines across all relevant insurance carriers • Coordinate with the clinical and medical teams to gather necessary documentation for authorization requests, including clinical notes, treatment plans, physician orders, and supporting records • Follow up proactively with clinical staff when documentation is incomplete, missing, or requires additional detail to meet payer criteria • Communicate clearly with internal teams about what is needed, why it is needed, and the urgency of the timeline • Ensure all clinical documentation is organized, complete, and appropriately formatted before submission • Maintain an accurate and up-to-date tracking log of all submitted authorization requests, pending decisions, and authorization statuses • Monitor payer portals and fax queues regularly for updates, approvals, denials, and requests for additional information • Proactively follow up with payers on pending authorizations that are approaching deadlines or have not received timely responses • Communicate authorization status updates to relevant internal stakeholders, including clinical and billing teams, as decisions are received • Identify cases where a peer-to-peer review has been requested by the payer or may be beneficial following a denial • Coordinate peer-to-peer review scheduling between the payer and the appropriate treating or ordering provider • Prepare relevant clinical documentation and case summaries to support the provider in advance of the peer-to-peer call • Follow up on peer-to-peer outcomes and ensure the resulting authorization decision is documented and acted upon appropriately • Identify and troubleshoot authorization delays, payer requests for additional information, and other barriers to timely approval • Escalate complex denials, coverage disputes, or payer issues to the appropriate internal team member with thorough documentation • Maintain a follow-up schedule for open authorization issues and ensure nothing is left unresolved or unmonitored • Communicate resolution outcomes to clinical, billing, and operational stakeholders as appropriate
Job Requirements
- Prior experience in a utilization management, prior authorization, or insurance authorization role in a healthcare setting
- Solid understanding of the insurance prior authorization process including submission via fax and payer portals
- Familiarity with payer-specific authorization requirements and the ability to navigate multiple payer portals efficiently
- Experience coordinating with clinical teams to gather and organize medical documentation for authorization submissions
- Strong attention to detail and organizational skills — authorization requests must be accurate, complete, and submitted on time
- Comfortable managing a tracking system for multiple open authorization cases simultaneously
- Reliable and self-directed in a remote work environment — deadlines are firm and follow-up is expected without prompting
- Clear written and verbal communication skills for coordinating with clinical staff and internal stakeholders
- Experience coordinating peer-to-peer reviews between payers and treating providers
- Familiarity with medical necessity criteria frameworks such as InterQual or MCG (Milliman Care Guidelines)
- Background in behavioral health, specialty care, or a high-authorization-volume clinical setting
- Experience using electronic health record (EHR) systems and insurance payer portals for authorization management
- Knowledge of HIPAA regulations and proper handling of protected health information (PHI)
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