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About The Role  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 is responsible for drafting, editing, and formatting 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 is a fast-paced, productivity-driven role that requires strong attention to detail, sound judgment, and the ability to manage competing priorities.

Primary Responsibilities

+ Review denied authorization cases within the Utilization Management system to understand the clinical determination and supporting rationale prior to letter creation or finalization.

+ Draft, edit, and format denial and partial denial letters based on authorization determinations, including accurately copying and inserting approved clinical statements, criteria citations, and physician rationale into correspondence 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.

Essential Qualifications

+ 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, including Word, Excel, and Outlook, in a Windows-based environment.

+ Ability to adapt quickly to changing business needs and learn new processes and systems.

Preferred Qualifications

+ Proficient in electronic medical records understanding 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 CPT4 and ICD-10 codes.

+ Previous Member Service or Customer Service telephonic experience.

About

At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion, and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all your unique abilities.

Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes, and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions. Come be a part of the Brightest Ideas in Healthcare™.

Company Mission

Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.

Company Vision

Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.

DEI Purpose Statement

At BHPS, we encourage all team members to bring your authentic selves to work with all your unique abilities.   We respect how you experience the world and welcome you to bring the fullness of your lived experience into the workplace.  We are building, nurturing, and embracing a culture focused on increasing diversity, inclusion and a sense of belonging at every level.

*We are an Equal Opportunity Employer

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