Utilization Management Coordinator I

The level I UM Coordinator is responsible for administrative functions in processing Utilization Management (UM) organization determinations for services requiring authorization and hospital notification. Utilizing knowledge of Medicare and Medicaid guidelines to facilitate and comply with the UM processes in data entry of authorization requests, eligibility verification, benefit determinations, timely letter fulfilment, and support to UM clinical staff.

- Have an associate degree, or an equivalent combination of education and highly relevant experience.

- Have at least one (1) year of customer service experience, preferred.

- Have working experience in a Healthcare setting, preferred.

- Have working experience in a Managed Care setting, preferred.

- Are knowledgeable of medical terminology and healthcare processes, preferred.

- Are knowledgeable of Washington Apple Health and Medicare Advantage Plans, preferred.

- Performs data entry for all referral, prior authorizations and hospital notifications; attaches and/or includes clinical documents as needed.

- Utilizes knowledge to determine appropriate CPT, HCPC, ICD-10 codes using CMS, NCQA and HCA criteria.

- Researches and validates benefit and prior authorization requirements to determine appropriate course of action within the Care Management system.

- Reviews, corrects, and approves authorization requests via the web portal; determines appropriate level of complexity and refers cases requiring clinical review to a nurse reviewer.

- Reviews completed denial letters for accuracy and adherence to compliance deadlines. Edits and proofreads content for appropriate medical terminology and MCG criteria. Ensures letters are mailed within established timeframes.

- Accurately applies policies & procedures, benefit and eligibility standards to all incoming requests.

- Conducts research, validates data, and responds to complex inquiries from multiple sources, including but not limited to members, nurses, medical providers, customer service, operations, appeals, case management and care coordination. Escalating issues as needed.

- Reporting to work on time and for all scheduled shifts is essential to this position.

- Solid analytical skills and the ability to interpret, evaluate and formulate action plans based upon data.

- Effective verbal and written communication skills. Able to communicate with and collaborate effectively with physicians and allied health care providers.

- Flexibility and willingness to work in a matrix-management environment.

- Demonstrated organizational, time management, and project management skills.

- Ability to multi-task and deal with complex assignments on a frequent basis.

- Demonstrated proficiency and experience with Microsoft Office products.

- Collaborate with others in a respectful manner and ability to maintain confidentiality.

The position is FLSA Non-Exempt and is not eligible for overtime. Based on market data, this position grade is 38 (see full range below) and has a 5% annual incentive target based on company, department, and individual performance goals.

- Ability to learn and prioritize multiple tasks at a given time and have the capability of handling demanding situations. Analytical/problem solving/critical thinking ability.