Utilization Management Coordinator
About the Role:
We are looking for a talented and motivated Utilization Management Coordinator to join our team! In this role, you will support clinical staff through completion of the administrative components of Utilization Management (concurrent, urgent, and routine pre-service, as well as retrospective authorizations) and Case/Disease management (authorizations, basic care coordination). The coordinator is responsible for processing and monitoring the authorization process and corresponding documentation continuously for quality and accuracy while working independently within a team environment. This position exercises considerable discretion and independent judgment in the performance of duties and responsibilities.
Essential Duties and Responsibilities:
· Prioritize, maintain, coordinate, process accurate and timely inpatient admission, and post-discharge authorizations (examples include DME, Home Health, Transportation); assist clinical staff in transition of care coordination (authorizations, PCP/Specialist appointments) and case/disease management programs (authorizations, basic care coordination). Process and issue member and provider NOA notifications (mail, fax, electronic media, telephone).
· Establish, facilitate, and maintain effective ongoing relationships with network hospitals, SNFs, delegated groups, vendors, and providers; facilitate communication and care coordination between network entities.
· Utilize established UM guideline pathways for screening, authorizing, and finalizing authorization (inpatient, outpatient, retrospective) requests.
· Reconcile daily hospital census reports and face sheets against plan’s authorization records; Maintain and communicate daily inpatient census and weekly discharge reports to hospitals.
· Run scheduled and ad hoc reporting on utilization data, including “hold” status authorizations; identify trends.
· Work with Medical Director, UM Management, and clinical staff as well as other departments to receive, date, document and resolve inquiries/issues for claims, authorizations, appeals and eligibility. Perform these duties in a professional and timely matter. This includes performing a preliminary processing of complaints and grievances.
· Process and approve authorization requests according to MSO and established clinical guidelines.
· For complex cases, research additional relevant clinical guidelines and information from accredited sources.
· Facilitate Care Coordination activities with members, families, specialist, and ancillary providers for authorized services.
· Provide excellent customer service regarding UM inquires to Primary Care Physicians, specialists, and affiliated members.
· Stay current with state and federal regulations, Health Plan agreements, and Industry Standard guidelines applicable to healthcare programs.
· Communicate UM related information and updates to all members of the health care team, patients, and their families.
· Accurately interpret and communicate member benefits and serve as a resource for nurses and the IT Department in verifying and resolving member eligibility.
· Respond to provider, member, and staff inquiries at any given time in a professional and timely manner.
· Work closely with clinical personnel to better understand the reasons for modification, deferral, or denial of an authorization request.
· Maintain, coordinate, and prioritize authorizations to UM nurses, vendors, and hospitals in a timely manner as needed.
· Complete other duties and special projects as assigned.
- Bachelor’s degree in Health Care Administration or related discipline or a minimum of 4 years of related experience.
- 3+ years of experience within Utilization Management in a health care setting.
- Working knowledge of managed care, ancillary and hospital-based services, DME and Home Health Services.
- Knowledge of medical terminology including RVS, CPT, ICD-9, ICD-10, and CPT 4 codes.
- Completion of a recognized Medical Assistant degree or certificate a plus.
- Demonstrated ability to work collaboratively, multi-task and meet deadlines in a complex, rapidly evolving environment with staff across the organization/departments.
- Proficiency in MS Office suite.
- Strong attention to detail and critical thinking, problem solving and analytical skills.
- Strong interpersonal, communication, organizational and time/project management skills are essential.
- Excellent written and verbal communication skills.
For more information about Trivium, visit www.trivium.com Interested applicants may forward a résumé, cover letter and references to the attention of Ramya at email@example.com.
We are an Equal Opportunity/Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources. EEO is the Law: poster_screen_reader_optimized.pdf