Medical Coordinator

Responsibilities

• Support daily operations of the UR process, ensuring adherence to internal policies and jurisdictional regulations.
• Collaborate with UR vendor partners to resolve issues and improve process delivery.
• Identify and escalate process trends, issues, or compliance risks to Senior Product Specialist/ UR and/or Senior Manager.
• Respond to inquiries from internal business partners and external providers within 24-48 hours.
• Support regulatory compliance by helping establish and enforce policies and procedures.
• Conduct quality assurance (QA) reviews to ensure accuracy and compliance with clinical guidelines and legal requirements.
• Participate in regulatory or internal audits as needed.
• Assist with training, coaching, and assisting in mentoring UR Coordinators and new team members if appropriate.
• Support performance tracking efforts and recommend development plans and performance targets.
• Promote team growth through feedback and continuous improvement initiatives.
• Work with the Senior Product Specialist/ UR to produce and review UR performance metrics and reports (e.g., completion rates, denial rates, appeal overturns).
• Analyze data to detect inefficiencies or risk areas and recommend improvements.
• Participate in department projects and initiatives as assigned.
• Provide support to the Senior Product Specialist/ UR or Senior Manager when needed.

Requirements

• 1-2 years of experience in Utilization Review or related healthcare setting
• Strong knowledge of state-specific UR regulations and clinical guidelines (e.g., ODG, ACOEM)
• Experience analyzing and resolving UR processing issues
• Prior process/procedure support experience
• Proficiency in UR platforms (e.g., MedReview, UR Express)
• Experience with claims systems (e.g., Claim Center)
• Excellent problem-solving, time management, and organizational skills
• UR platform proficiency
• Familiarity with ICD-10, CPT codes, and medical terminology
• Skilled in Microsoft Outlook and Excel
• Strong documentation and electronic communication skills
• Effective communication and relationship-building skills
• Adaptability in a fast-paced, deadline-driven environment
• Ability to support, influence, and assist in mentoring a team