UM Coordinator

The Utilization Management Coordinator is responsible for supporting clinical, management, and client activities that comprise the UM Program. The Utilization Management Coordinator must be proficient in all UM processes such as and understanding of the CCS process, what requires precertification from health plan, Division of Financial Responsibilities, Delegation agreements and Health Plan contracts. The UM Coordinator will ensure we are processing quality referrals in a timely manner meeting the health plan standards.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Comply with all UM policies and procedures. Annual review of selected UM policies.
• Process Routine, Urgent & Retro treatment authorization requests according to the S&S Policy & Procedure and Health Plan turn-around time standards. S&S will use these timeframes for consistency
  • Pharmacy requests 24 hrs
  • Urgent 72 hrs- Calendar days
  • Routines 5 days- Business days
  • Part B Drugs 24 hrs
• Maintain understanding of business rules and regulatory requirements pertaining to UM processes and operations
• Accurately review, screen and process daily assigned UM referrals (average 200 referrals/day) in accordance with IPA and health plan TAT guidelines
  • Coordinator will check that all required fields are completed correctly. If missing DX and or CPT a call will be made to the provider while they are screening.
  • Coordinators will use level 1 guidelines to release referrals that meet specific business rules
    • If benefit check required document what specifics are to be checked
  • If referral requires clinical review or are above a Level 1 guideline, the referral is sent to the nurse queue for review. Urgent and or Routine nurse queues.
• Contact the provider office as needed for clarification of ICD 10 or CPT codes and or to request medical records.
• Maintain high level of accuracy when processing referrals. Random audits will be done to verify.
• Responsible for verification to include but not limited to: benefit matrix through DOFR, eligibility, provider status (contracted/non-contracted), CCS, carved out and others.
• Responsible for obtaining authorization approvals from the appropriate physician assigned to that IPA.
• Monitor reports to ensure that the coordinators are meeting the established TAT.
• Work the inquiry emails to respond to UM questions from Member services or provider relations.
• If assigned to work the Medical Director queue, the coordinator will process as per the Medical Directors instruction.
  • Coordinator will release those that are approved
  • Coordinator will populate the required fields for the denial and or redirection and forward to the denial team to process the request.
• Attend to provider and interdepartmental calls in accordance with exceptional customer service
• Ability to keep high level of confidence and discretion when dealing with sensitive matters relating to

providers and members.

• Report any issues to Supervisor and or Manager.
• Maintains strictest confidentiality at all times.

OTHERS:

· Back up to Supervisor or Manager when he or she is not available.

· Maybe required to cover occasional weekend and or holiday to maintain our required TAT.

· Attend to provider and interdepartmental calls in accordance with exceptional customer service

· Maintain good relationships with health plans and medical directors and external contacts.

· Performs other duties, projects and actions as assigned

· Team-player, assist others as needed in order to comply with TAT.

· Support departmental initiatives such as policy/procedure review, audit preparation

· Other duties as assigned

QUALIFICATIONS:

• High School Graduate or equivalent
• A minimum of two years experienced in managed care environment to include but not limited to an IPA or MSO preferred.
• Current knowledge of Managed Care UM procedures
• Knowledge of medical terminology, RVS, CPT, HPCS, ICD-9 codes.
• Proficient with Microsoft applications’ and EZCAP
• Good organizational skills.
• Good verbal and written communication skills.
• Must have the ability to multitask and problem solve in a fast pace work environment
• Personal & Professional Qualities

• Punctuality, precision with details, creativity, etc. would be helpful for this position
• Ability to follow directions and perform work independently according to department standards
• Able to function effectively under time constraint
• Able to maintain confidentiality at all times
• Willingness to accept responsibility and desire to learn new task
• Ability to comply and follow company policies and procedures
• Must be a strong team player, punctual and have excellent attendance record.