Job Description

The Sr. Medical Coordinator supports the Senior Product Specialist/ UR in supporting the day-to-day operations of the Utilization Review function. This role provides supportership, quality oversight, data analysis, and guidance on regulatory compliance, ensuring efficient, accurate, and timely UR determinations. The UR Coordinator also assists with escalations, supports internal audits, and plays a key role in assist in mentoringing and developing the UR team.

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.
• Demonstrate commitment to Company’s Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards and laws applicable to job responsibilities in the performance of work.

Qualifications

• 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