The Utilization Management (UM) Coordinator will support clinical staff through completion of the administrative components of Utilization Management (concurrent, urgent and routine pre-service, as well as retrospective authorizations) and Case/Disease management (authorizations, basic care coordination). The 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) and case/disease management programs (authorizations, basic care coordination). 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.
· 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.
· 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:
· One 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 and problem solving skills.
· Ability to work in cooperation with others.
· 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 resource to department staff.
· Working ability with Microsoft Office suite.
$24.56 - $36.84/hour