Utilization Review Coordinator(

Utilization Review Coordinator( Waterbury, CT Job Details Full-time 1 day ago Qualifications Master's degree in social work Collaborate with healthcare professionals Appeals Computer operation Master of Social Work Insurance prior authorization Inpatient Utilization review Electronic health records (EHR) management Achieving HIPAA compliance LMSW Word processing Computer literacy Insurance claim appeals processing Licensed Clinical Social Worker Social work HIPAA Mid-level CMS regulatory compliance InterQual Case management Utilization management Quality improvement Centers for Medicare and Medicaid Services (CMS) Clinical documentation Medical insurance appeals management Discharge planning Working with individuals with mental health conditions Patient progress monitoring Productivity software Social Work Care coordination Hospital regulatory compliance Escalation handling Interdisciplinary behavioral health coordination Communication skills Technical Proficiency Hospital experience Negotiation Full Job Description

JOB SUMMARY

The Inpatient Behavioral Health Social Worker in Utilization Review is responsible for evaluating the medical necessity, appropriateness, and efficiency of behavioral health services provided to patients in an inpatient setting. This role ensures compliance with regulatory standards and payer requirements while supporting optimal patient care and resource utilization. The role integrates and coordinates utilization management and denial prevention by focusing on identifying and removing unnecessary and redundant care, promoting clinical best practice, and ensuring all patients receive "the right care, at the right time, and in the right setting".

KEY RESPONSIBILITIES

Conduct utilization reviews for inpatient behavioral health admissions, concurrent stays, and discharge planning. Apply clinical criteria (e.g., InterQual, Milliman) to assess medical necessity and level of care. Collaborate with physicians, nurses, and treatment teams to ensure appropriate care delivery. Demonstrates thorough knowledge in the application of behavioral health criteria Communicate with insurance providers to obtain authorizations and manage denials or appeals. Communicates payor criteria and issues on a case-by-case basis with multidisciplinary team and follows up to resolve problems with payors as needed; initiates peer to peer when appropriate. Contacts the attending physician for additional information if the patient does not meet the appropriate medical necessity criteria or in accordance with CMS rules and regulations for continued stay. Supports multi-disciplinary strategies to reduce length of stay, reduce resource consumption, and achieve positive patient outcomes. Maintain accurate documentation of reviews, authorizations, and clinical decisions. Monitor patient progress and recommend transitions to lower levels of care when appropriate. Participate in interdisciplinary team meetings and contribute to care coordination. Ensure compliance with HIPAA, CMS, and other regulatory guidelines. Identify high-risk cases and escalate concerns to clinical leadership as needed. Support quality improvement initiatives related to utilization management. Performs all other duties as assigned.

QUALIFICATIONS/REQUIREMENTS

Master's degree in Social Work (MSW). Active state licensure (e.g., LCSW, LMSW). 2+ years of experience in behavioral health, preferably in inpatient or managed care settings. Prior experience in utilization review or case management strongly preferred. Familiarity with clinical review tools (InterQual, Milliman). Strong understanding of behavioral health diagnoses, treatment modalities, and discharge planning. Excellent communication, negotiation, and documentation skills. Proficiency in electronic health records (EHR) and utilization management software.

COMPETENCIES

• Comprehensive knowledge of the health care reimbursement system.
• Demonstrated skill in creative problem solving, facilitation, collaboration, coordination, and critical thinking.
• Excellent demonstrated oral, written and communication skills.
• Proficiency in the use of work processing and spreadsheet application.

Working knowledge of healthcare reimbursement and available community resources. Must have strong computer skills and the ability to access internet and other programs applicable to Waterbury Hospital procedures. Perform automated functions that fall within job responsibility.

Location:

Waterbury Hospital

Case Management Schedule:

Full Time, Days, 8am - 430pm