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