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Utilization Management Coordinator II

at AltaMed

Posted: 9/28/2019
Job Reference #: 8493

Job Description

  • LocationUS-CA-Commerce
    Job ID
    Clinical Services
  • Overview

    This position is responsible for providing support to the Medical Management department to ensure timeliness of outpatient or inpatient referral/authorization processing per state and federal guidelines. This position performs trouble-shooting when problems situations arise and takes independent action to resolve complex issues.


    1. Input data into the Medical Management system to ensure timeliness of referral/authorization processing.
    2. Verifies member benefits and eligibility upon receipt of the treatment authorization request.
    3. Utilizes authorization matrix, ancillary rosters, DOFR, and/or delegation agreements to drive decision-making.
    4. Coordinates with referral nurse and/or Medical Director for timely referral processing.
    5. Ensure timely provider and member oral and written notification of referral decisions.
    6. Ensures proper notification of patient facility admissions with PCP and NOMNC when applicable.
    7. Coordinate board certified referrals with partner vendors.
    8. Coordinates and assists with patient appointments as needed and notify patient of authorization status.
    9. Performs trouble-shooting when problems situations arise; taking independent action to resolve complex issues.
    10. Prepares denial letters for review by Medical Director or Nurse Reviewer(s) and distributes letters to appropriate recipients.
    11. Performs coordination for out-of-network cases and facilitates letters of agreement (LOA) processing in collaboration with Medical Directors and Leadership.
    12. Performs coordination of benefits.
    13. Demonstrates excellent communications skills and interpersonal relationships.
    14. Collaborates and facilitates interdisciplinary team communications.
    15. Perform additional duties as assigned.
    16. Process referrals and/ or calls within the dept. targets based on workflows and technology.
    17. Meets inter-rater minimum standards for core responsibilities.
    18. If assigned to Provider Phone Queues, Collaborates with Customer Service Representatives to provide information regarding referral/authorization processing.
    19. Appropriately tracks incoming call types and pertinent details of calls.


    1. High School Diploma or equivalent required.
    2. MA or Medical Billing Certificate preferred.
    3. Minimum 2 years of experience working in a medical billing environment (IPA or HMO preferred), with pre-authorizations and reimbursement regulations pertaining to Medi-Cal, CCS and other government programs required.
    4. Prior experience in utilization management processing authorization referrals also required.
    5. Prefer prior Lead position experience.
    Not ready to apply? Connect with us for general consideration.