Utilization Review Administrator

Description If you are looking for employment with a purpose where you can help improve the daily lives of the members of your community, then consider a career with Pioneer Human Services! We are currently looking for a Utilization Review Administrator with a passion for human services. This is an exciting opportunity to be involved with an organization focused on a transformative path towards social change, creating pathways for rehabilitation, reintegration, and redemption. Who we are – Our Mission We empower justice-involved individuals to overcome adversity and reach their full potential. For over 60 years, we have proudly serviced our clients with professionalism and empathy. We are a nationally recognized non-profit with 35+ locations across Washington state that provided a chance for change to over 9,500 individuals in 2024. What We Offer At Pioneer, our employees are important. That’s why we offer a Total Rewards package that includes compensation and benefits to support employees' health, security, and balance. Compensation New hires for this position typically start between $19.86 and $24.82 hourly, depending on factors such as work location, experience, qualifications, skills, competencies, internal equity, and market conditions. While the full pay range is provided to support pay transparency, individual compensation will vary within the range based on these factors. Benefits That Invest In You At Pioneer, we offer a comprehensive benefits package designed to support your health, financial well-being, and continued growth. Health & Wellness Benefits Medical coverageDental coverageVision coverageFlexible Spending Account (FSA)Dependent Care Flexible Spending Account Financial Protection Employer-provided life insuranceAccidental Death & Dismemberment (AD&D) insuranceDisability coverage Invest in Your Future Front-Loaded Tuition AssistanceRetirement PlanEmployee recognition programsPublic transportation discountsEmployee Assistance Program (EAP) Join Pioneer and build more than a career. Be part of a team that supports your well-being, recognizes your contributions, and invests in your future. Benefit eligibility, coverage, contributions, and program provisions are subject to the terms of the applicable benefit plans and policies. What you'll do As the Utilization Review Administrator you will help control costs, improve revenue collection, and ensure data integrity. The Utilization Review (UR) Administrator critically examines guest medical records for completeness and accuracy to ensure appropriate funding and authorizations are in place for timely and accurate payment. This position works closely with clinical, leadership and administrative staff to ensure Pioneer receives accurate and timely payment for services provided. Primary/essential Duties And Responsibilities Are But Not Limited To Monitors utilization patterns including daily census, no-shows, and AMAs and notifies leadership of potential utilization issuesReviews bed boards daily to ensure accuracy Ensures initial authorizations, episodes, and bed boards are completed in a timely and accurate mannerMonitors, tracks, and analyzes required reportsMaintains applicable UR documentation in Electronic Medical Record (EMR)Conducts peer-to-peer review with MCO to appeal denialsSubmits appeals for denied authorizations with applicable clinical, demographic, and payer informationCoordinates, monitors, and tracks resolution of revenue cycle tickets to help resolve funding and other related, non-clinical, client issuesEnsures clients have access to services while ensuring the client’s right to be in the least restrictive environment as clinically appropriateUnderstands and applies MCO, CMS, and insurance requirements for pre-authorization, authorization, concurrent, retrospective, and peer-to-peer review for individuals admitted under voluntary treatment statusEnsures excellent customer service is provided to payers, vendors, and internal customers Maintains access to Quick Mar, EHR, payer portals and other required systems Composes and sends professional communication related to medical records and case coordination Works with UR Coordinator to ensure length of stay for each program is within authorization durationMonitors and provides appropriate staff updates for authorizations and length-of-stay; assists with transition for continued stays, discharges, or transfersCollaborates and partners with billing, clinical staff, management, UM team, and finance to ensure data accuracy, operational efficiency, timely financial collection, and adequate task coverage Maintains working knowledge and collaborative relationships with community partners and resourcesPromotes and models teamwork and collaboration with coworkersMaintains quality of care consistent with or exceeding standards set by federal, state, local, internal, and contract requirements Adheres to professional and ethical standards for behavioral health services Develops internal UR policies and procedures Guides staff in proper completion of clinical documentation to ensure accuracy and quality client care Maintains current knowledge of federal and state regulations for Medicaid, Medicare, private insurance/managed care, and other related industry programs and practicesAssists with training staff to ensure operational efficiency What you'll bring High school diploma/GED1 year of experience working in substance use, medical or mental health fields 1 year of experience working with individuals with behavioral health conditions Preferably you'll bring Associates Degree in health care, business, or related field 1-year administrative experience in the healthcare or related field (i.e. billing, data entry, invoicing)Experience working in a residential treatment facility EEO Pioneer human services is an equal opportunity employer of minorities/women/individuals with disabilities/protected veterans and does not unlawfully discriminate under federal, state, or local laws. All qualified applicants will receive consideration for employment without regard to race, color, religion, national origin, gender, sexual orientation, gender identity, age, physical or mental disability, or protected veteran status. EEOC is the Law/EEO Policy Statement Pioneer Human Services is a Drug-Free Company Pioneer Human Services is a drug free company. Pioneer’s existing drug-free workplace policy prohibits the use of marijuana, including medical marijuana, and complies with Washington law. As such, this position is subject to drug testing during employment, to include testing for marijuana