Utilization Reviewer

Job Summary

Responsible for managing and coordinating the complete process of prior authorization, inpatient and outpatient admission reviews, surgical case approvals, appeals, and denial management. Utilizes IQC and MCG Guidelines to evaluate clinical admissibility and ensure compliance with insurance requirements. Collaborates with providers, nursing staff, and insurance companies to secure timely approvals, improve documentation accuracy, and enhance overall case management efficiency.

Key Responsibilities

- Review and process prior authorizations for inpatient, outpatient, and surgical cases as per insurance and clinical guidelines.

- Assess medical necessity and admission admissibility using IQC and MCG Guidelines.

- Coordinate with physicians, nursing teams, and providers to ensure accurate and complete documentation for authorization.

- Submit medical documents and authorization requests to insurance companies with accuracy and timeliness.

- Manage denials and appeals, prepare supporting documents, and follow up with payers until resolution.

- Arrange and facilitate peer-to-peer reviews between attending providers and the insurance medical director.

- Maintain and routinely update admission logs, denial logs, and follow-up trackers with outcomes.

- Identify documentation gaps and work with clinical and administrative teams for continuous documentation improvement.

- Stay updated on payer-specific authorization requirements, policy changes, and utilization review standards.

Required Skills and Qualifications

- Strong knowledge of utilization review and authorization workflows across inpatient and outpatient services.

- Working familiarity with ICD-10 and CPT coding frameworks.

- Proficient in applying IQC and MCG Guidelines to assess medical necessity.

- Experience in appeals and denial management, with strong coordination and communication skills.

- Ability to maintain detailed documentation, track authorization outcomes, and meet timelines effectively