Lead Inpatient Utilization Management Coordinator / Job Req 772063236

PRINCIPAL RESPONSIBILITIES :

The Lead IP Utilization Management (UM) Coordinator, under the direction and supervision of the Inpatient UM Clinical Supervisor, is responsible for the monitoring of the daily activities of the non clinical administrative components of Utilization Management (concurrent, urgent, routine pre-service, and retrospective authorizations) to ensure quality, timeliness and accuracy of processes and documentation. This position involves front line problem solving of the day-to-day routine tasks of the non - clinical support staff. The Lead is a content expert and guides the Inpatient UM Coordinator Staff in processing and monitoring of authorizations and corresponding documentation continuously for quality and accuracy, while working independently within a team environment. The Lead ensures requests are completed in a timely and efficient manner in line with Standard Operating Procedures, Policies and Procedures, and regulatory standards (DHCS, DMHC and NCQA). This position serves as a mentor to the staff for guidance and / or first line decision making, as well as a resource to other internal departments and team members. This position exercises considerable discretion and independent judgment in the performance of duties and responsibilities.

Principal responsibilities include :

• Prioritize, maintain, coordinate, and process accurate and timely inpatient admission, concurrent review authorizations and discharge related authorization requests (including but not limited to acute, subacute, skilled nursing, acute rehab, LTACH, elective surgery, DME, home health, transportation, dialysis, hospice)
• Monitor department platforms to identify potential delays in processing of incoming requests via ADT feed, FAX, Provider Portal, telephone, and other methods for receiving authorization requests. Work with staff to identify root cause for delays and implement changes to ensure timely movement of case work into TruCare for management and processing. Assist staff with platform processing as necessary.
• Assist clinical staff with completion and / or delegation of nonclinical tasks including Care Coordination (examples include DME, home health, follow up appts, Transportation) and Care Management referrals including TCS, ECM, Complex CM, referrals for Community Supports Services)
• Ensure requests are prioritized, maintained, coordinated and processed accurately and timely to meet all regulatory turnaround times.
• Utilize multiple platforms to review member eligibility status including primary, secondary, delegates. Communicate with providers and re-route requests through the appropriate method of communication.
• Serve as resource and initial point of leadership contact for non-clinical staff and for operational questions and issues related to members both internally and externally; coordinate with OP UM, LTC, Case Management, Provider Services, Claims and other departments to implement solutions
• Maintain working knowledge of regulatory requirements for DHCS, DMHC and NCQA and apply to daily work, adhering to department workflows for Continuity of Care, in network, out-of-network, out-of-area and delegate management.
• Assure compliance with all payer contracts and delegated network Division of Financial Responsibility (DOFRs) as related to prior authorization rules.
• Maintain knowledge of 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), level of urgency, eligible diagnoses for California Children's Services, tertiary / quintenary services, benefits / benefit limitations, applicable global days
• Ensure accurate documentation of UM activities within the UM platform to ensure proper claims payment with hospital, delegates, vendors, and providers.
• Maintain accurate documentation of internal NOA letter audits.
• Support leadership with onboarding of new team members by providing training in UM platforms, acting as a resource for new staff, and provide feedback to leadership.
• Assist leadership with external regulatory audits including DHCS, DHMC and NCQA : data gathering, file assembly and bookmarking.
• Reconcile daily hospital census reports and face sheets against plan's authorization records; Maintain and communicate daily inpatient census and weekly discharge reports to hospitals.
• Generate and prepare census reports for rounds with external providers.
• Oversee extended stay rounds report, train new staff on utilization.
• Complete monthly hospital confinements report for finance team.
• Utilize multiple electronic medical record systems to extract information for reviewers and working within scope.
• Maintain and update protocols and contacts for requesting access to electronic medical record systems, guide and train new staff on obtaining, follow up and maintaining access.
• Follow protocol and process disenrollment requests and : fax requests to Healthcare Options, follow up on request status, send Notice of Action and Last Covered Day letters when necessary, and escalate to compliance department when necessary. Provide training and oversight to new staff on steps and procedures.
• Review and audit coordinator work and processes to ensure adherence to applicable regulations for DHCS, DMHC and NCQA. Address any non-adherence with the Supervisor for management.
• Triage non-clinical issues and escalate to Supervisor / Manager if unable to resolve
• Establish, facilitate and maintain effective internal and external relationships
• Work with Medical Director, UM Management, and clinical staff as well as other departments to resolve inquiries / issues for claims and authorizations
• Review aging reports related to authorizations and notifications, identify issues and problems, and work collaboratively to effect changes to address above referenced issues and problems.
• Provide initial onboard training and remedial training of staff to ensure successful integration into the team.
• Conduct team huddles and educational activities for frontline staff to ensure adherence to departmental and regulatory workflows.
• Participate in quality improvement initiatives / projects as the UM representative as required.
• Serve as SME for UM process and software database(s)
• Work proactively with provider and community resources to identify areas of opportunity and / or education needs.
• Ensures department goals in authorization management and TAT are met.
• Provide administrative support when necessary to ensure productivity and TAT
• Utilize established UM guideline pathways for screening, authorizing and finalizing authorizations.
• Meet annual performance goals established for the position. Assist leadership to ensure front line associate performance goals are met.
• Complete other duties and special projects as assigned.

ESSENTIAL FUNCTIONS OF THE JOB :

PHYSICAL REQUIREMENTS :

Number of Employees Supervised : 0

MINIMUM QUALIFICATIONS :

EDUCATION OR TRAINING EQUIVALENT TO :

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE :

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE) :

SALARY RANGE : $46.03 - $69.04 Hourly

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.

Salary : $46 - $69