Utilization Review Coordinator

About the role

HPI is a respected industry leader with over 44 years of experience, known for innovation and adaptability in providing health and benefit solutions to employers. As a third-party administrator, we tackle challenges head-on and seek individuals passionate about making a real impact for employers and employees nationwide. Our supportive and inclusive work environment fosters innovation and invests in team growth and well-being.

Responsibilities

• Review clinical information to determine medical necessity, appropriate level of care, and length of stay using standardized clinical criteria.
• Render positive determinations for cases meeting criteria; refer others for physician peer review.
• Gather relevant clinical information from healthcare providers.
• Confirm medical necessity for procedures and services; refer cases to Peer Reviewer if criteria are not met.
• Conduct utilization management for level of care and length of stay using standardized criteria.
• Consult with Peer Reviewers when criteria are insufficient or additional input is needed.
• Provide timely case screening to identify case management needs and generate referrals.
• Ensure timely follow-up on outstanding utilization management issues and inquiries.
• Collaborate with healthcare providers to identify discharge needs and facilitate timely transitions.
• Communicate with providers and professionals regarding the Utilization Management process.
• Ensure case documentation adheres to policy and procedure.
• Proactively manage professional growth by collaborating with your Manager.
• Demonstrate consistent application of standardized criteria for interrater reliability.
• Maintain satisfactory quality audit scores.
• Manage work time and caseload efficiently.
• Adhere to HIPAA policies and procedures.

Requirements

• A minimum of three years of experience in an acute care clinical setting.
• Active, current, and unrestricted professional licensure as an RN (Registered Nurse) or LPN (Licensed Practical Nurse) in Massachusetts, Maine, New Hampshire, or state of residency.
• Proficiency in Microsoft Office, including Word, Excel, Outlook, and PowerPoint.

Benefits

• Medical, Dental, Vision, and Prescription Drug Coverage.
• Fitness Reimbursement Benefit.
• Employee Assistance Program.
• Flexible Spending Account & Health Savings Account.
• 401(k) and Quarterly Bonuses.
• Generous Paid-Time Off & Volunteering Opportunities.
• Educational Assistance & Professional Development Opportunities.

Our workspace reflects our innovative, open, and collaborative culture, featuring ergonomic desks and a "smart casual" dress code. At our Westborough headquarters, you can recharge in the onsite café, walk on beautiful trails, or work out at one of the campus gyms.