• Utilization Management Coordinator

    Location US-CA-Alameda
    Posted Date 1 month ago(4/20/2018 3:33 PM)
    Job ID
    2018-1779
    # of Openings Remaining
    1
    Experience (Years)
    1
  • Overview

    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.

    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.

     

     

    PHYSICAL REQUIREMENTS:

     

    · 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.

    Qualifications

    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.

     

    Pay Range: 

    $24.56 - $36.84/hour

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