Utilization Management Coordinator

US-CA-Irvine
Req No.
2017-2161
Category
Clinical/Medical
Type
Regular Full-Time

Overview

ConcertoHealth delivers comprehensive care to Medicare, Medicaid, and complex-needs patients. For over a decade, we have provided extraordinary outcomes for thousands of people in these underserved groups.

The ConcertoHealth name reflects our unique approach to healthcare. It’s about how we work in concert with patients, providers, and health plans. It’s about the harmony of a patient’s care, health, and dignity.

 

 

Summary:

The UM Coordinator position is a liaison between the patient and specialty providers and other ancillary services to ensure benefit requirements are met by requesting authorizations.  The UM Coordinator will keep the patient and providers informed during the process. 

Responsibilities

  • Performs data entry of referral authorization request for primary care visits, specialty consults, diagnostic/outpatient procedures and admissions approved by the Medical Director
  • Tracks and monitors progress of referral request, responding to request for additional information to assist the clinical staff in making a decision
  • Reviews all incoming referral request for completeness of information provided
  • Obtains CPT procedure codes, ICD-10 diagnosis codes from referring providers to assist with determination of approval/denial
  • Ensures that network providers are utilized
  • Handles incoming calls from physicians, ancillary providers, and patients regarding referral authorization request
  • Monitors and facilitates reauthorization request for home health, DME and other services according to benefit guidelines
  • Coordinates all out of network outpatient referrals to specialist with the Medical Director
  • Generates all required letters and notifications to patients and providers regarding referral authorizations
  • Maintains/updates all required reporting for referrals/authorizations
  • Complete other duties and special projects as assigned

 

 

Qualifications

  • High School diploma or GED
  • 2-4 year experience in managed care or health care setting
  • Knowledge of Medical Terminology
  • Typing 45wpm
  • Ability to navigate multiple PC applications simultaneously. Knowledge and experience using Microsoft ® Office required
  • Possess an understanding of Managed Care including referral requirements
  • Excellent written/verbal communication skills, especially the ability to communicate telephonically in a professional and effective manner, especially in stressful situation
  • Display patience and demonstrates respect for callers and staff. Maintains composure in high pressure situations
  • Strong organizational and time management skills. Able to work independently, but also as a team player
  • Ability to convey a positive and professional image to customers and employees
  • Willingness to embrace and promote change as required by the needs of the business 

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