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Utilization Coordinator


The Utilization Manager will be responsible for the collection, review and submission of all managed care paperwork submitted to the Kepro and/or the MCO organization for programs operating in the state of West Virginia. This person has responsibility for oversight of the entire process. They will provide technical assistance and training to all and any staff as necessary to appropriately secure funding for services provided. Including, but not limited to documentation of services and units, file reviews, staff credentialing and other duties as assigned. The Utilization Manager will also be responsible for Child Nutrition monitoring, coordination of menu cycle with the dietitian, and high level program implementation, application, and monitoring.

Essential Roles and Responsibilities

Assure prior authorization and maintenance of payment for services

To assure prior authorization and continuous payment for services the Utilization Coordinator will:

  • act as the primary liaison with the designated Kepro, Aetna or designated MCO care manager for the organization;
  • assure that responsibilities are covered in their absence through identification of a back up person and provision of necessary training;
  • review of all Kepro, Aetna or designated MCO paperwork for accuracy and completion prior to submission;
  • notification of staff of inaccurate or incomplete paperwork and responsibility for corrective training as necessary;
  • development of a state wide system of Kepro, Aetna or designated MCO documentation completion that assures timeliness and accuracy by service line as necessary;
  • data entry of Kepro, Aetna or designated MCO paperwork on a daily basis to meet required timelines;
  • problem solve with program or leadership staff as necessary when authorizations are pended or closed.

Provide technical assistance and training to staff regarding Kepro, Aetna or designated MCO process

To assure that staff are trained regarding Kepro, Aetna or designated MCO requirements the Utilization Coordinator will:

  • assist staff in understanding Kepro, Aetna or designated MCO and Medicaid guidelines by clarifying regulation and policy over the telephone, on site and through preparation of easy to understand written materials;
  • develop trainings as necessary for all level of staff to assure accurate documentation of services and submission of accurate and timely authorizations
  • work with state clinical staff, program directors and senior directors to communicate any changes in Kepro, Aetna or designated MCO expectations and incorporate into trainings in a timely manner;
  • communicate regularly with care manager to develop ongoing relationship and quick lines of communication;
  • assist leadership in identifying issues/barriers around the authorization process to support corrective plans as needed;

Collaborate with programs and state leaders on all State Audit related actions regarding Kepro, Aetna or designated MCO process

To assure continued quality improvement regarding Kepro, Aetna or designated MCO activities the Utilization Coordinator will;

  • coordinate credentialing process with state leadership and credentialing committee;
  • assist in quarterly client file reviews;
  • communicate with Kepro, Aetna or designated MCO regarding audits, coordinate audit from provider side;
  • communicate with auditors regarding feedback and follow up training as needed;
  • assist in the development and implementation of effective data management systems as required;
  • assist in the analysis of collected data to ensure integrity;
  • participate on state level service line committees as needed;
  • coordinate or complete meeting minute documentation as needed

Child Nutrition Program monitoring and liaison responsibilities

To assure continued compliance with the Child Nutrition Program through application, reporting, monitoring and information sharing with the Child Nutrition program and the designed residential program the Utilization Manager will:

  • share information from the Child Nutrition Program with the residential program;
  • assure applications and continued participation through assuring requirements, monitor, documentation, etc. is provided;
  • work with the dietitian and the residential program to assure menu cycles are created and implemented;
  • attend training and share training information with the residential program;
  • conduct monitoring reviews as required;
  • liaison between the Child Nutrition Program and Pressley Ridge for WV;
  • assure understanding and provide updates and changes to the residential program;
  • submit documentation for annual funding allotment;
  • assure the ongoing participation in the Child Nutrition Program.

Working Conditions

  • Physical Demands. Requires vision, speech, and hearing.
  • Environmental Factors. Office, Community
  • Working Hours. Primarily traditional hours; may be needed occasional evenings or weekends for staff support and training. Full-time positions are based on a 40-hour work week.

Clearances. State Police/FBI per state regulations; Child Protection

EducationBachelors of Human Services (required)
ExperienceKnowledge and understanding of program paperwork; program funding mechanisms and program leadership structures (required)
computer skills & knowledge of data entry (required)
supervisory experience (preferred)
2 years: relevant experience (required)

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)
Clarksburg, WV, 26301, US