Under the general direction of the Utilization Management Manager with supervision and accountability to the Medical Director and within the Coordinator scope of practice, the UM Coordinator is responsible for working directly with Providers, contracted entities and vendors to ensure coordinated, continuous cost effective quality healthcare for plan embers.
This position is a full-time, Monday - Friday (8:00-5:00) in-office position with growth and leadership opportunities.
Major Functions (Duties And Responsibilities):
Responsible for gathering of clinical documentation to assist the Medical Director with decision of prospective/pre-service, concurrent or retrospective reviews based on clinical criteria for appropriateness of outpatient and inpatient services and care.
Responsible for concurrent hospital, SNF, and home health review. Receive regular care updates from attending providers and care coordinators.
Arrange transition of care between patient settings including discharging and receiving coordination and referral submission and approval.
Support inpatient case management department.
Responsible for UM related inbound and outbound /follow-up calls.
Responsible for preparation of regular status reports and updates to partnered IPA and physician groups. Participate in preparation of delegated reports for payers and regulatory bodies.
Works collaboratively with the UM team to ensure regulatory timeframes are upheld for authorization of concurrent, outpatient or ancillary services as per approved clinical criteria, including but not limited to, specialist referrals, outpatient surgery, durable medical equipment, home health, etc.
Serves as a resource for Golden Coast MSO Member and Provider Service departments for utilization management, referral, and continuity of care issues.
Works with Contracts Department to identify gaps in provider network.
Responsible for assisting with the letter of agreement process when referring to Members to out-of-network providers.
Responsible for timely and appropriate documentation in the medical management system.
Assist with identifying potential cases for Case Management, Disease Management, Health Education and/or quality of care issues and making appropriate referrals when needed.
Assist with identifying alternate payer sources such as CCS, IRC, etc.
Responsible for working with Team Members to support the goals of the department and the vision of the organization.
Receive phone calls and assist with provider requests for authorization status updates, extensions, and modifications.
Process all authorizations through Quick Cap managed care processing software.
Adhere to all company Policy and Procedures as well as Code of Conduct.
Identify carve out services and coordinate care with provider for member access to care.
Data entry of faxed referrals and review for coordinator level for approval
Verify eligibility, benefits and address other referral request related services from providers and their office staff.
Required Experience:
Two (2) plus years of utilization management experience in a health care delivery setting.
Preferred Experience:
Experience in an HMO, IPA, or Managed Care setting preferred.
Education Qualifications:
High school diploma or GED required
Preferred Education:
Associates or Bachelor's degree preferred
Knowledge Requirement:
Knowledge of Title 22, Title 10, DMHC, DHCS, and CMS regulatory requirements. ICD-9/10 and CPT coding.
Knowledge of capitated managed care environment helpful. MediCal, Medicare and other state/federal Program & Regulations.
Knowledge of division of financial responsibility (DOFR) contracts preferred.
Knowledge of benefit plans preferred.
Skills Requirement:
Computer skills required and proficiency in Windows applications preferred.
Proficiency in Excel strongly preferred.
Excellent communication and interpersonal skills.
Strong organizational skills.
Professional demeanor.
Commitment to Team Culture.
Working Conditions:
Must be able to sit, walk, and stand. Must be able to use hands and fingers to operate equipment including, but not limited to, computers, phones, and stationery. Must occasionally lift up to 25 pounds. Must be able to view screens and monitors 90% of the time while stationary.
Work Environment:
This position is an in-office position.
About us:
Golden Coast MSO was founded to create a proactive, easy to work with management services organization. Seeing an opportunity to provide exceptional professional services, our team came together to design an MSO that prioritizes provider and patient needs.
We are an expanding organization looking to build a team committed to excellence and professional growth. We value proactive and honest individuals who can create simple and effective systems which place patients' needs first.