UTILIZATION MANAGEMENT COORDINATOR I MSO
About The Position
The Utilization Management Coordinator I functions under the direct supervision of a physician or Registered Nurse, performing utilization management (UM) and care coordination duties for the NEMS MSO. ESSENTIAL JOB FUNCTIONS: Review daily all incoming Referral Requests and Treatment Authorization Requests for inpatient and outpatient services. Process and approve authorization requests according to the NEMS MSO Authorization Grid and to established clinical guidelines. Must meet the quantitative productivity standard of 250 authorizations per week for the outpatient UM Coordinator and 115 authorizations per week for the inpatient UM Coordinator. For complex cases, research additional relevant clinical guidelines from different sources. Responsible to prepare and present complex cases to Medical Director for review; confirm Medical Director’s approval/modification/denial decision for record tracking. Perform Care Coordination activities with members, families, specialists, and ancillary providers for authorized services. Perform customer service for UM inquiries to Primary Care Physician, specialist, and members. Stay current with DHCS regulations, Health Plan agreements, and Industry Standard guidelines applicable to healthcare programs. Communicate UM related information and updates to all members of the health care team, patients, and their families. Follow the appropriate turnaround timeframe for decisions and notification of members and providers. Performs other job duties as required by manager/supervisor.
Requirements
- Completion of a 2-year degree or higher.
- Knowledge of medical terminology.
- Excellent data entry skills.
- Strong communication, analytical, and problem-solving skills.
- Knowledge of community resources and cultural needs.
- Good organization and prioritization skills, outstanding in time management.
- Recent experience in a clinic or outpatient setting desirable; able to perform efficiently and appropriately in a busy environment.
- Must be able to fluently speak, read and write English.
Nice To Haves
- Completion of a recognized Medical Assistant degree or certificate a plus.
- Working knowledge of managed-care a plus.
- Fluent in Chinese (Cantonese and/or Mandarin) preferred.
- Fluent in other languages is an asset.
Responsibilities
- Review daily all incoming Referral Requests and Treatment Authorization Requests for inpatient and outpatient services.
- Process and approve authorization requests according to the NEMS MSO Authorization Grid and to established clinical guidelines.
- Must meet the quantitative productivity standard of 250 authorizations per week for the outpatient UM Coordinator and 115 authorizations per week for the inpatient UM Coordinator.
- For complex cases, research additional relevant clinical guidelines from different sources.
- Responsible to prepare and present complex cases to Medical Director for review; confirm Medical Director’s approval/modification/denial decision for record tracking.
- Perform Care Coordination activities with members, families, specialists, and ancillary providers for authorized services.
- Perform customer service for UM inquiries to Primary Care Physician, specialist, and members.
- Stay current with DHCS regulations, Health Plan agreements, and Industry Standard guidelines applicable to healthcare programs.
- Communicate UM related information and updates to all members of the health care team, patients, and their families.
- Follow the appropriate turnaround timeframe for decisions and notification of members and providers.
- Performs other job duties as required by manager/supervisor.
Benefits
- Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
Associate degree
