Utilization Coordinator

About the role

The Utilization Coordinator proactively monitors patient service utilization to ensure optimal reimbursement and compliance with managed‑care requirements. Working closely with clinical staff and insurance partners, the role supports efficient length‑of‑stay management and quality reporting.

Key responsibilities

• Act as liaison between managed‑care organizations and clinical teams, communicating reimbursement criteria.
• Review insurance plans and coordinate documentation for pre‑certifications, admissions, and continued stays.
• Monitor patient length of stay, identify extensions, and alert staff to factors affecting discharge.
• Collect and analyze statistical and narrative data on utilization, non‑certified days, and quality metrics for leadership reports.
• Conduct medical necessity and quality reviews, and facilitate peer‑review calls with external entities.
• Initiate and manage formal appeal processes for denied admissions or continued stays.
• Provide training and ongoing support to staff on documentation, charting, and medical necessity updates.
• Perform additional duties as assigned by management.

Required profile

• High school diploma or equivalent; associate’s, bachelor’s or master’s degree in social work, behavioral health, nursing, or related field preferred.
• Clinical experience required, or at least two years working with the facility’s patient population.
• Preferred background in utilization management.
• Relevant licensure (LPN, RN, LMSW, LCSW, LPC, etc.) and CPR, de‑escalation, restraint certification; first‑aid certification may be required.

Required skills

• Knowledge of insurance reimbursement processes and managed‑care guidelines.
• Ability to collect, analyze, and report utilization data.
• Experience conducting medical necessity and quality reviews.