Utilization Management Coordinator I

Overview: This position is responsible for providing support to the Medical Management department to ensure timeliness of outpatient or inpatient referral/authorization processing per state and federal guidelines. This position performs trouble-shooting when problems situations arise and coordinates with leadership.Responsibilities:

• Input data into the Medical Management system to ensure timeliness of referral/authorization processing.
• Verifies member benefits and eligibility upon receipt of the treatment authorization request.
• Utilizes authorization matrix, ancillary rosters, DOFR, and/or delegation agreements to drive decision-making.
• Coordinates with referral nurse and/or Medical Director for timely referral processing.
• Ensure timely provider and member oral and written notification of referral decisions.
• Ensures proper notification of patient facility admissions with PCP and NOMNC when applicable.
• Coordinate board certified referrals with partner vendors.
• Coordinates and assists with patient appointments as needed and notify patient of authorization status.
• Performs trouble-shooting when problems situations arise and coordinates with leadership.
• Prepares denial letters for review by Medical Director or Nurse Reviewer(s) and distributes letters to appropriate recipients.
• Demonstrates excellent communications skills and interpersonal relationships.
• Collaborates and facilitates interdisciplinary team communications.
• Perform additional duties as assigned.
• Process referrals within the dept. targets based on workflows and technology.
• Meets inter-rater minimum standards for core responsibilities.

Qualifications:

• High School Diploma or equivalent required.
• MA or Medical Billing Certificate preferred.
• Minimum 1 year of experience working in a medical billing environment (IPA or HMO preferred), with pre-authorizations and reimbursement regulations pertaining to Medi-Cal, CCS and other government programs required.
• Prior experience working in a clinic/health care specialty call center.
• Prefer experience in utilization management processing authorization referrals.