Under the direction of the Assistant Director of Utilization Management, the UM Coordinator works as a team member of the UM Department. They process various types of authorizations such as inpatient admission, observation, outpatient procedures, imaging, DME, home health, PT/OT/ST, genetic testing, drugs, psychological services, chiropractic, acupuncture services, etc., in collaboration with RN/LVN Case Managers. The Coordinator verifies eligibility, confirms benefits and DOFR, and processes requests according to established UM guidelines. They handle a large volume of authorizations electronically and via facsimile, compose and respond to emails, and manage the telephone queue for both providers and members. The UM Coordinator should possess a solid understanding and experience of UM processes, including Medicare, Commercial, and Medi-Cal programs, benefits, and policies. They also address retro UM authorizations related to claims resolution. Additionally, the UM Coordinator assists members in navigating the complex health system, facilitating care redirection, appointment scheduling, resource coordination, and resolution of any barriers related to authorization or access to care. Other related duties may be assigned.

• Three (3) years of recent experience working in an HMO, IPA, and MSO payer environment.

• Experience processing prior authorizations for Commercial, Medi-Cal, or Medicare membership.

• Experience and thorough understanding of DOFR as it applies to authorizations and UM delegation.

• Strong knowledge of CPT/ ICD codes, minimum health plan benefits, Appeals & Grievances, retro auth processing for outpatient and inpatient, and letter templates.

• Experience with claims/EOB from a payer perspective with the ability to research EOBs.

• Experience with appeals and grievances and processing approval and denial letters.

• Excellent communication skills both verbally and in writing. Excellent customer service skills handling provider calls.

• Skilled in MS Office (Excel, PowerPoint, Outlook, Word, RightFax, etc.). Must possess strong technical and analytical skills.

• Demonstrated ability to coordinate and research the review of difficult, complex Utilization Management issues.

• Experience within high volume HMO or IPA/MSO utilization management /prior authorization department is highly preferred.

• Good knowledge of HMO benefits/policies for authorization; Understanding of Division of Financial Responsibility (DOFR).

• Strong understanding of Medicare, Commercial health plan benefits.

• Experience with processing retro claims/UM authorizations/appeals/grievances.

• Electronic Medical Record/ Epic experience.

• Experience working on a multidisciplinary team.

• Must be able to work various hours and locations based on business needs.
• Employment is subject to a criminal background check and pre-employment physical.
• Holiday and weekend availability required.
• Employee required to have consistent high-speed internet and appropriate workstation when working remotely.