Job Overview:
The Utilization Management Coordinator is responsible for supporting the Medicare UM department by coordinating functions and completing administrative and clerical duties as assigned including, but not limited to, intake of and resolutions for initial determinations and appeals, and providing support to members, providers and interdisciplinary staff.
Essential Responsibilities:
- Accurate creation/capturing of member; member representative; or provider authorization requests and processing as per plans prior authorization policies and procedures.
- Accurate creation/capturing of member; member representative; or provider appeal requests and processing as per plans policies and procedures.
- Processing of prior authorization outcomes including auto approvals and requests reviewed by delegated entities as per plans policies/ procedures and workflows.
- Processing of appeal outcomes/resolutions as per plans policies/ procedures and workflows.
- Create and maintain spreadsheets as needed for tracking of requested information including but not limited to, initial determinations, appeals, provider data.
- Provide consistent daily phone coverage and demonstrate the ability to manage a high volume of telephone communication with members, providers, and internal departments.
- Communicate effectively with providers to obtain clarification or additional information when needed to appropriately process requests.
- Assists staff within team to facilitate workflow(s) and ensure efficient service to our members and providers.
- Identify and escalate questions or issues when information is unclear or additional clarification is required.
- Review available information in the member's record to identify overlapping or duplicate requests and avoid unnecessary duplication of work or requests.
- Work collaboratively and cohesively with other departments and team members to facilitate efficient workflows and ensure timely resolution of requests.
- Ability to manage a high volume of work while maintaining accuracy and meeting established productivity expectations.
- Ability to meet established productivity, timeliness, and quality expectations.
- Reliable attendance and availability to support daily departmental operations.
- Other activities as directed
Specific Knowledge, Skills, and Abilities:
- Proficiency in Microsoft Office and Excel
- Healthcare experience, preferred
Required Education, Experience, and Licenses:
Benefits:
- Medical, dental, and vision insurance
- Generous PTO package
- Multiple floating holidays
- 401 (K) with employer contribution
