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Utilization Management Coordinator II
- Job ID
- Clinical Services
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.
- Input data into the Medical Management system to ensure timeliness of referral/authorization processing.
- Verifies member benefits and eligibility upon receipt of the treatment authorization request.
- Utilizes authorization matrix, ancillary rosters, DOFR, and/or delegation agreements to drive decision-making.
- Coordinates with referral nurse and/or Medical Director for timely referral processing.
- Ensure timely provider and member oral and written notification of referral decisions.
- Ensures proper notification of patient facility admissions with PCP and NOMNC when applicable.
- Coordinate board certified referrals with partner vendors.
- Coordinates and assists with patient appointments as needed and notify patient of authorization status.
- Performs trouble-shooting when problems situations arise; taking independent action to resolve complex issues.
- Prepares denial letters for review by Medical Director or Nurse Reviewer(s) and distributes letters to appropriate recipients.
- Performs coordination for out-of-network cases and facilitates letters of agreement (LOA) processing in collaboration with Medical Directors and Leadership.
- Performs coordination of benefits.
- Demonstrates excellent communications skills and interpersonal relationships.
- Collaborates and facilitates interdisciplinary team communications.
- Perform additional duties as assigned.
- Process referrals and/ or calls within the dept. targets based on workflows and technology.
- Meets inter-rater minimum standards for core responsibilities.
- If assigned to Provider Phone Queues, Collaborates with Customer Service Representatives to provide information regarding referral/authorization processing.
- Appropriately tracks incoming call types and pertinent details of calls.
- High School Diploma or equivalent required.
- MA or Medical Billing Certificate preferred.
- 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.
- Prior experience in utilization management processing authorization referrals also required.
- Prefer prior Lead position experience.