The Lead Utilization Management (UM) Coordinator is responsible for overseeing the day to day routine task of support clinical staff through completion of the administrative components of Utilization Management (concurrent, urgent and routine pre-service, as well as retrospective authorizations). The Lead Coordinator is responsible for processing and monitoring the authorization process and corresponding documentation continuously for quality and accuracy while working independently within a team environment. This position exercises considerable discretion and independent judgment in the performance of duties and responsibilities.
Principal responsibilities include:
· Prioritize, maintain, coordinate, process accurate and timely inpatient admission and post-discharge authorizations (examples include DME, Home Health, Transportation); assist clinical staff in transition of care coordination (authorizations, PCP/Specialist appointments. Process and issue member and provider NOA notifications (mail, fax, electronic media, telephone).
· Establish, facilitate and maintain effective ongoing relationships with network hospitals, SNFs, delegated groups, vendors and providers; facilitate communication and care coordination between network entities
· Utilize established UM guideline pathways for screening, authorizing, and finalizing authorization (inpatient, outpatient, retrospective) requests.
· Reconcile daily hospital census reports and face sheets against plan’s authorization records; Maintain and communicate daily inpatient census and weekly discharge reports to hospitals.
· Run scheduled and ad hoc reporting on utilization data, including “hold” status authorizations; identify trends.
· Work with Medical Director, UM Management and clinical staff as well as other departments at the Alliance to receive, date, document and resolve inquiries/issues for claims, authorizations, appeals and eligibility. Perform these duties in a professional and timely matter. This includes performing a preliminary processing of complaints and grievances.
· Receive and respond to claims issues related to an authorization, research issues; and assist with determining the root cause.
· Accurately interpret and communicate member benefits and serve as resource for nurses and the IT Department in verifying and resolving member eligibility.
· Respond to provider, member, and staff inquiries at any given time in a professional and timely manner.
· Review daily and trend aging reports related to authorizations and notifications, identify issues and problems,, and work collaboratively to effect changes to address above referenced issues and problems.
· Work closely with clinical personnel to better understand the reasons for modification, deferral, or denial of an authorization request.
· Maintain, coordinate, and prioritize authorizations to UM nurses, vendors, and hospitals in a timely manner as needed.
· Complete other duties and special projects as assigned.
ESSENTIAL FUNCTIONS OF THE JOB:
· Communicate and coordinate with PCPs, specialists, hospitals, other providers, and internally.
· Communicate effectively, both verbally and in writing.
· Multi-task and prioritize.
· Provide administrative support.
· Perform writing, administration, and data entry into multiple systems.
· Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
· Constant and close visual work at desk or computer.
· Constant sitting and working at desk.
· Constant data entry using keyboard and/or mouse.
· Frequent use of telephone headset.
· Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
· Frequent lifting of folders and other objects weighing between 0 and 30 lbs.
· Frequent walking and standing.
· Occasional driving of automobiles.
EDUCATION OR TRAINING EQUIVALENT TO:
· Bachelor’s degree or higher in a healthcare related area of study – or -
· AS/AA degree or two (2) years of college with a minimum of one year experience making healthcare related assessments and referrals, and/or experience in working with diverse clients with multiple barriers – or -
· High school diploma and equivalent combination of education and/or experience
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
· 2-4 year experience in managed care or health care setting preferred.
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
· Excellent verbal and written communication skills.
· Ability to work within guidelines and protocols to achieve decisions independently.
· Excellent critical thinking, problem solving and research skills.
· Ability to work in a team-oriented structure to achieve goals.
· Demonstrate skill working collaboratively with others at various levels.
· Ability to prioritize multiple projects as well as work for a number of other employees.
· Working knowledge of managed care, ancillary and hospital-based services, DME and
Home Health Services.
· Knowledge of medical terminology including RVS, CPT, ICD-9, ICD-10, and CPT 4 codes.
· Ability to act as a lead resource to department staff.
· Working ability with Microsoft Office suite.