Clinical Services UM Coordinator

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    "requisitionDescription": "<div><div><p><br></p><p data-pasted=\"true\"><u><strong>Primary Purpose:</strong></u></p><p style=\"margin-left:0in;\">Data input of referral authorization requests received from the Organization&#39;s Contracted Providers; generate member notifications as directed.&nbsp;</p><p><u><strong>Principal Duties and Responsibilities (* = essential functions):</strong></u></p><ul style=\"list-style-type: disc;margin-left: -0.25in;\"><li>Verifies eligibility and benefits for each referral. *</li><li>Performs data entry of referral authorization requests for primary care visits, specialty consults, diagnostic/outpatient procedures, and admissions approved by the Medical Director. *</li><li>Tracks and monitors progress of referral requests, responding to requests for additional information to assist the medical director&#39;s staff in making a decision. *</li><li>Primary telephone call process for incoming calls into the Utilization Management Department. *</li><li>Provides referral and authorization notifications to providers as directed. *</li><li>Organizes and maintains electronic and hard copy filing systems for authorizations/referrals as directed.&nbsp;</li><li>Prepares assigned correspondence and reports and complies with statistical data as directed.&nbsp;</li><li>Tracks all types of references on the computer system on a hard copy log and compiles statistics monthly.&nbsp;</li><li>Supports and facilitates teamwork within the department/group and the organization.&nbsp;</li><li>Obtains CPT procedure codes and ICD-10 diagnosis codes from referring providers to assist with the determination of approval/denial.&nbsp;</li><li>Ensures that network providers are utilized.&nbsp;</li><li>Handles incoming calls from physicians, ancillary providers, and patients regarding referral authorization requests.&nbsp;</li><li>Review file for completeness of required documentation, including but not limited to confirmation of receipt of notification copies of written notification correspondence with members and providers.&nbsp;</li><li>Monitors and facilitates requisition requests for home health DME and other services in accordance with benefit guidelines.&nbsp;</li><li>Coordinates all out-of-network outpatient specialist referrals with the Medical Director.&nbsp;</li><li>Generates all required letters and notifications to patients and providers regarding referral authorizations, medical approval, and medical denial within established timeframes in accordance with policies, procedures, and contractual requirements.&nbsp;</li><li>Provide the requested information during the appeals process.&nbsp;</li><li>To organize and act promptly on pending denial files/cases to maintain designated turnaround times and physician communication.&nbsp;</li><li>To provide information to licensed nursing staff regarding referrals that are &#39;not a covered benefit&#39; and facilitate denial letters.&nbsp;</li><li>To organize, manage, and prioritize workload effectively to process authorization request forms within the established time frame. *</li><li>To refer appropriate authorization request forms to the IPA case manager based on established criteria.&nbsp;</li><li>To educate and inform physicians and their office staff of any changes to the referral process, network changes, or other information about the referral process.&nbsp;</li><li>Assist other departments in creating denial documentation during the appeals process.&nbsp;</li><li>Document denial and denial rationale in data management systems. *</li><li>Maintains/updates all required reporting for referrals/authorizations.&nbsp;</li><li>Complete other duties and special projects as assigned.&nbsp;</li><li>Ensure all required work is completed on time by the end of each shift.&nbsp;</li><li>Participates in scheduled departmental/group meetings.&nbsp;</li><li>Represents the department/group and organization professionally and positively.&nbsp;</li><li>To perform other duties as assigned.&nbsp;</li></ul><p><u>Job Specifications (KSAs):</u></p><ul style=\"list-style-type: disc;margin-left: -0.25in;\"><li>Six months of experience in the medical field, either in a hospital, clinical, or insurance setting, that includes experience with computers.</li><li>The ability to read, write, and speak English and perform other basic educational skills, as is generally obtained by completing High school or a GED equivalent.</li><li>Bilingual English/Spanish preferred.</li><li>Clear and accurate knowledge of medical terminology; managed care experience and knowledge preferred.</li><li>Working knowledge &amp; expertise of ICD-10 &amp; CPT-4 codes.</li><li>Demonstrated computer literacy. Excel experience helpful.</li><li>Excellent communication skills in both oral and written modes, as well as superior telephone etiquette.</li><li>Excellent Customer Service experience and proficiency required.</li></ul><p>Pay Range $18 - $27.00 hourly DOE.</p><p><br></p><p><br><br></p><p><br></p></div></div>\n",
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