UM Denials Coordinator

UM Denials Coordinator

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BHPS provides Utilization Review services to its clients. The UM Denials Coordinator supports the Utilization Management function by reviewing denied and partially denied authorizations and preparing denial correspondence within the Utilization Management system. This role drafts, edits, and formats denial and partial denial letters to ensure clarity, accuracy, completeness, and appropriate readability while maintaining compliance with regulatory requirements and client-specific service level agreements.

The position works closely with physicians and nursing staff and may require follow-up phone calls or email communication to clarify determinations, obtain additional information, or resolve discrepancies prior to letter release. The UM Denials Coordinator reports to the Clinical Services team and performs a range of moderately complex administrative and operational tasks in support of UM activities. This fast‑paced, productivity‑driven role requires strong attention to detail, sound judgment, and the ability to manage competing priorities.

• Review denied authorization cases within the Utilization Management system to understand the clinical determination and supporting rationale before letter creation
• Draft, edit, and format denial and partial denial letters based on authorization determinations, accurately copying approved clinical statements, criteria citations, and physician rationale into templates
• Apply working knowledge of Utilization Management processes and sound judgment to ensure all written correspondence is clear, readable, complete, and accurate
• Ensure all letter content, data fields, and member, provider, and service details are accurately populated to prevent compliance risks or downstream operational issues
• Communicate with physicians and nursing staff as needed to clarify determinations, obtain missing information, or resolve discrepancies prior to letter release
• Prioritize and triage denied authorization cases in alignment with client‑specific requirements and regulatory turnaround times
• Respond to and resolve member and provider inquiries related to denied authorizations and denial correspondence
• Review, investigate, and resolve items listed on the failed fax report to ensure timely and successful delivery of correspondence
• Perform other related duties as assigned

• High school diploma or GED required
• Two or more years of healthcare administrative support experience
• Two or more years of managed care experience in Utilization Management or Appeals
• Strong verbal and written communication skills
• Demonstrated customer service skills, including effective written and verbal communication
• Proficient in Microsoft Office applications (Word, Excel, Outlook) in a Windows‑based environment
• Ability to adapt quickly to changing business needs and learn new processes and systems

• Proficient in electronic medical records and medical record documentation
• 2‑4 years’ experience as a medical assistant, office assistant, or other clinical experience
• Previous experience handling/reviewing UM denial letters
• Proficient/experienced with CPT‑4 and ICD‑10 codes
• Previous member service or customer service telephonic experience

Brighton Health Plan Solutions, LLC, is committed to improving how healthcare is accessed and delivered. Our culture focuses on encouragement, respect, and increasing diversity, inclusion, and a sense of belonging at every level. We partner with self‑insured employers, Taft‑Hartley Trusts, health systems, providers, and other TPAs, offering flexible & cutting‑edge third‑party administration services. Our proprietary provider network and innovative technology platform enable clients to enhance the member experience and achieve healthcare goals.

Entry level

Full‑time

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