Utilization Review Coordinator(

Utilization Review Coordinator(

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 :

COMPETENCIES :

Waterbury Hospital procedures.

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