Outpatient Utilization Management Coordinator / Job Req 704970317

PRINCIPAL RESPONSIBILITIES:

The Utilization Management (UM) Coordinator will support clinical staff through completion of the administrative and nonclinical coordinator functional components of Utilization Management The Coordinator is responsible for continuous processing and monitoring of the review and authorization process and ensuring the quality, timeliness and accuracy for corresponding documentation. The OP coordinator must be able to multi-task and work independently within a team environment. This position exercises considerable discretion and independent judgment in the performance of duties and responsibilities while complying with any and all regulatory requirements.

Principal responsibilities include:

• Prioritize, maintain, coordinate, process accurate and timely inpatient elective and outpatient prior authorization requests (PA).. Types of PAs may include holistic, DME, radiology, allergy, advanced laboratory services, medication, dialysis, Home Health, orthotics/prosthetics, Rehab

• Identify regulatory overlay requirements in addition to general PA process which includes but is not limited to: eligibility (primary, secondary, delegate), in network (INN), out of network (OON), OON reason(s), continuity of care (CoC), standing referral status, duplicity, level of urgency, eligible diagnoses for California Children's Services, tertiary/quaternary services, benefits/benefit limitations, applicable global days

• Prepare applicable letter generation for determination outcomes (approvals and denials)

• Accurately document UM activities with the UM platform to ensure proper claims payment with hospital, delegates, vendors and providers

• Facilitate communication and care coordination between network entities

• Serve as initial point of contact for operational questions and issues related to members both internally and externally; coordinate with UM, Case Management and other departments to implement solutions

• Demonstrate a comprehensive understanding of coverage and benefits in order to promote appropriate service utilization for DHCS, DMHC and NCQA

• Ensure authorizations are completed timely to meet all regulatory turnaround times

• Research complex issues and bring to resolution.

• Assist leadership during and following onboarding of new hires to serve as a resource for ongoing support to support successful integration into the team

• Manage incoming phone calls through OP UM Customer Call center while processing authorizations

• 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.

• 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.

• Assist Manager with preparation of files for Health Plan audits for DHCS, NCQA and DMHC

• 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

• Meet annual performance goals established for the position

• 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.

• Strong organizational and problem solving skills, detail-oriented

• Be able to multi-task and prioritize within an ever-changing environment

• Ability to work independently and effectively within a team environment

• Ability to analyze and interpret requests to properly identify member needs and applicable regulatory requirements based on the request. Ability to work deftly within multiple platforms simultaneously (auth data base platform, provider portal, claims system, eligibility system, Right fax, AR platform, translation portal, external verification websites)

• Ability to anticipate risk/issues and prevent them from happening

• Able to demonstrate ability to meet production requirements for both case work and call center

• Sensitivity to a diverse, low income community

• Provide administrative support.

• 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.

Number of Employees Supervised: 0

MINIMUM 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 two years of applicable experience

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• One year experience in managed care or health care setting preferred.

• Direct Medi-Cal experience within a managed care environment preferred

• Medicare and commercial experience a plus

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 de-escalate situations with customers and bring to resolution

• 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 medical terminology including RVS, CPT, HCPCS and ICD-10, coding Ability to act as resource to department staff.

• Proficient with Microsoft Office suite.

SALARY RANGE $92,051.06-$138,076.59 ANNUALLY

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.