UM Coordinator

Location: Orange, CA
Date Posted: 10-05-2017
UM Coordinator
Orange,California

Summary
The UM Coordinator assist and supports the clinical team (UM Nurse/Medical Director) with administrative task related to processing Utilization Management’s clinical referrals.

Essential duties and responsibilities include, but are not limited to:
• Monitor Fax Folders 
• Verify eligibility and/or benefit coverage for requested services.
• Enter pre-service requests/authorizations in system using ICD 10 and CPT coding.
• Verify all necessary documentation has been submitted for pre-service request.
• Contact and request medical records, orders, and/or necessary documentation from requesting provider in order to process related pre-service requests/authorizations when necessary.
• Accurately documents referral process and any pertinent determination factors within the referral system. 
• Process pre-service request for medical services such as DME, office visits and radiology using approval criteria. 
• Assist with mailing or faxing correspondence to PCP’s, Specialists, related to requests/authorizations as needed.
• Contact members and maintain documentation of all for Expedited requests.
• Comply with tasks assigned by nurse and, as appropriate, documents accordingly.
• Answer queue calls relating to UM review and pre-service status.
• Recognize work-related problems and contributes to solutions.
• Meet specific deadlines (responds to various workloads by assigning task priorities according to department policies, standards and needs).
• Maintain confidentiality of information between and among health care professionals.
• Other duties as assigned by UM Supervisor.

Minimum Requirements
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Experience: Preferred 1-2 years’ experience in a medical setting working with IPAs, entering referrals/prior authorizations. Must of have knowledge of ICD 10, CPT codes, Managed Care Plans, medical terminology (certificate preferred) and referral system (Access Express/Portal/N-coder). 
2. Education: High School Diploma or general education degree (GED) and/or training; or equivalent combination of education and experience.
3. Certificates, Licenses, Registrations: No licensure required.
4. Knowledge of Medicare Managed Care Plans
5. Computer Skills: Word, Excel, Microsoft Outlook
6. Experience with the application of UM criteria (i.e., Apollo, CMS National and Local Coverage Determinations, etc.)
7. Bilingual (English/Spanish) preferred 
8. Positive, team player attitude

Skills and Abilities
1. Language Skills: Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors; 
2. Mathematical Skills: Ability to perform mathematical calculations and calculate simple statistics correctly
3. Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution; 
4. Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
5. Report Analysis Skills: Comprehend and analyze statistical reports.

Working Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Office setting  
2. The noise level in the work environment is usually moderate.
3. Duties performed primarily telephonically.
 
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