Utilization Management (UM) Coordinator

Position Summary

This position works collaboratively with the Case Managers, Claims Department, Credentialing and Contracting Department, and other Medical Management staff. The position requires strong written and communication skills and the ability to interact with Medical Directors, Providers, IPAs, Health Plans, and patients to ensure the delivery of high quality, cost effective healthcare.

Duties and Responsibilities

•Enters data and processes referral authorization requests, to include appropriate coding and quantities

•Answers incoming calls from Providers, IPAs, Medical Groups and other internal and external calls and assists on the queues as needed

•Follow up pending referrals to ensure that they are processed in a timely manner

•Educate providers as needed with the referral and authorizations process

•Verifies member eligibility before processing authorizations

•Identifies non-contracted providers and requests letter of agreements or contracts when needed

•Assist the credentialing and contracting department in obtaining contracts, letter of agreements, and other necessary tasks

•Requests supporting documentation from IPAs/Medical Groups as requested by the Case Managers

•Monitors the turn around time timeframes to ensure timely processing

•Contacts facilities identified by the Case/Care Manager/Director/Medical Director to research any issues (i.e., admissions, discharges)

•Assists the Case Managers in coordinating and arranging services for members.

•Assists the Claims Department

•Responds to variations in daily workload by evaluating task priorities according to department policies and standards.

•Maintains confidentiality of information between and among health care professionals

•Follow companies policies, procedures, and processes

•Other duties as assigned

Qualifications and Skills

•REQUIRED: Must be fluent in English. Strong writing, verbal, grammar, spelling, and punctuation skills

•Bachelor's Degree or Associate's Degree preferred

•Some clinical experience pertaining to utilization management

•Knowledge of CMS, DHS, DMHC, NCQA , and ICE guidelines

•Familiarity with MSOs, IPAs, HMO health plans

•ICD-10 and CPT coding experience

•Proficient computer skills with Microsoft Word, Excel, and Adobe Acrobat (PDF)

Resume submission : info330amm@gmail.com