Clinical Services UM Coordinator

Primary Purpose:

Data input of referral authorization requests received from the Organization's Contracted Providers; generate member notifications as directed.

Principal Duties and Responsibilities (* = essential functions):

• Verifies eligibility and benefits for each referral. *
• Performs data entry of referral authorization requests for primary care visits, specialty consults, diagnostic/outpatient procedures, and admissions approved by the Medical Director. *
• Tracks and monitors progress of referral requests, responding to requests for additional information to assist the medical director's staff in making a decision. *
• Primary telephone call process for incoming calls into the Utilization Management Department. *
• Provides referral and authorization notifications to providers as directed. *
• Organizes and maintains electronic and hard copy filing systems for authorizations/referrals as directed.
• Prepares assigned correspondence and reports and complies with statistical data as directed.
• Tracks all types of references on the computer system on a hard copy log and compiles statistics monthly.
• Supports and facilitates teamwork within the department/group and the organization.
• Obtains CPT procedure codes and ICD-10 diagnosis codes from referring providers to assist with the determination of approval/denial.
• Ensures that network providers are utilized.
• Handles incoming calls from physicians, ancillary providers, and patients regarding referral authorization requests.
• Review file for completeness of required documentation, including but not limited to confirmation of receipt of notification copies of written notification correspondence with members and providers.
• Monitors and facilitates requisition requests for home health DME and other services in accordance with benefit guidelines.
• Coordinates all out-of-network outpatient specialist referrals with the Medical Director.
• Generates all required letters and notifications to patients and providers regarding referral authorizations, medical approval, and medical denial within established timeframes in accordance with policies, procedures, and contractual requirements.
• Provide the requested information during the appeals process.
• To organize and act promptly on pending denial files/cases to maintain designated turnaround times and physician communication.
• To provide information to licensed nursing staff regarding referrals that are 'not a covered benefit' and facilitate denial letters.
• To organize, manage, and prioritize workload effectively to process authorization request forms within the established time frame. *
• To refer appropriate authorization request forms to the IPA case manager based on established criteria.
• To educate and inform physicians and their office staff of any changes to the referral process, network changes, or other information about the referral process.
• Assist other departments in creating denial documentation during the appeals process.
• Document denial and denial rationale in data management systems. *
• Maintains/updates all required reporting for referrals/authorizations.
• Complete other duties and special projects as assigned.
• Ensure all required work is completed on time by the end of each shift.
• Participates in scheduled departmental/group meetings.
• Represents the department/group and organization professionally and positively.
• To perform other duties as assigned.

Job Specifications (KSAs):

• Six months of experience in the medical field, either in a hospital, clinical, or insurance setting, that includes experience with computers.
• The ability to read, write, and speak English and perform other basic educational skills, as is generally obtained by completing High school or a GED equivalent.
• Bilingual English/Spanish preferred.
• Clear and accurate knowledge of medical terminology; managed care experience and knowledge preferred.
• Working knowledge & expertise of ICD-10 & CPT-4 codes.
• Demonstrated computer literacy. Excel experience helpful.
• Excellent communication skills in both oral and written modes, as well as superior telephone etiquette.
• Excellent Customer Service experience and proficiency required.

Pay Range $18 - $27.00 hourly DOE.