UM Referral Coordinator I - Bakersfield 1.1

Description Location: Bakersfield, CA. (Onsite) Classification: Full-Time This position is non-exempt and will be paid on an hourly basis. Schedule: Universal Healthcare MSO's standard operating hours are Monday through Friday, from 8:00 a.m. to 5:00 p.m. Pacific Time. Unless otherwise specified, all employees are expected to work their assigned schedules and remain available during these operational hours. To support business operations and after-hours member needs, employees within the Utilization Management (UM) department may be assigned schedules that differ from standard business hours. Candidates accepting a position within the department should be aware that work schedules may be adjusted based on operational requirements. Currently, the anticipated alternate schedule for this role is 9:00 a.m. to 6:00 p.m. Benefits: Medical Dental Vision Paid Time Off (PTO) Floating Holiday Simple IRA Plan with a 3% Employer Contribution Employer Paid Life Insurance Employee Assistance Program Compensation: The initial pay range for this position upon commencement of employment is projected to fall between $20.96 and $26.19. However, the offered base pay may be subject to adjustments based on various individualized factors, such as the candidate's relevant knowledge, skills, and experience. We believe that exceptional talent deserves exceptional rewards. As a committed and forward-thinking organization, we offer competitive compensation packages designed to attract and retain top candidates like you. Position Summary: Reporting to the Utilization Management leadership, the Referral UM Coordinator Leve I plays a pivotal role in furnishing essential clerical support and aiding the clinical team within the UM department on a day-to-day basis. This pivotal position assumes responsibility for efficiently handling a substantial volume of prior authorization requests. The UM Referral Coordinator Level I ensures that all orders and referrals align with the health plan's benefits and promptly escalates any exceptions to the UM clinical team. In adherence to UM guidelines and carve-out processes, certain authorizations are approved at a UM Coordinator level by the UM Referral Coordinator. This role also encompasses the critical task of validating eligibility, benefits, and contract status for requested providers. On a regular basis, the UM Referral Coordinator Level I interacts with various stakeholders, including UM staff, Medical Directors, other healthcare providers, health plans, and relevant personnel both within and outside the organization. The UM Referral Coordinator Level I diligently and accurately processes medical authorizations, strictly adhering to company and departmental policies and procedures. This includes meticulous verification of all submitted information for accuracy. Furthermore, this position assumes the responsibility of independently managing assigned tasks and activities, following established policies and procedures with precision and expertise. Job Duties and Responsibilities: Accurately processes medical authorizations according to company/department policies and procedures. General knowledge of CPT and ICD9/ICD10 and HCPCS codes relates to the processing of medical billing and/or authorizations. Familiar with medical terminology as it relates to IPA's, PPO's and HMO's Ability to interpret and communicate complex contract or benefit language. Strong problem-solving abilities. Ability to identify issues and problems within administrative processes and other relevant areas. Composes basic letters, faxes, & emails which are sent to various providers as it relates to authorizations. Works collaboratively with internal departments to obtain information or documentation required to accurately process authorizations. Verifies all information in EZCAP is correct and makes changes/ updates as necessary. Answers all authorization inquiries in a professional and positive manner ensuring that all information given is accurate. Conducts calls to providers, facilities, vendors for additional information on authorization requests, as needed. Place calls to members and providers regarding authorization outcome within the necessary notification timeframe. Monitors emails and/or faxes daily and appropriately distributes incoming faxed requests. Monitors the determination and notification Turn-Around Timeframes (TAT) and managing daily workload according to TAT requirements. Troubleshoot calls from members, providers, health plans, hospitals, and other business affiliates to facilitate a seamless UM service. Handles UM Department's mailing distribution and assisting in mail room, which may require scanning and inputting data in accordance with department practice. Implements patient discharge plans delegated by Inpatient UM Nurse by coordinating with home care agencies, post-acute care facilities, durable medical equipment companies, transportation agencies and others as indicated. Attentive to detail, accurate, thorough, and persistent in following through to completion of all activities, demonstrating initiative for completing work assignments. Excellent communication skills; able to read, write, and speak articulately, using established channels of communication and reporting relationships within the organization. Ability to communicate effectively with all levels of internal/external staff, management, members, physicians/physician office staff. Knowledge of generally accepted professional office procedures and processes. Ability to use the following general office equipment correctly and safely: desktop computer for data entry and typing, copy machine, scanner, facsimile machine, and telephone equipment. Ability to create professional documents using proper grammar and punctuation. Ability to handle various situations in a professional manner, always demonstrating excellent customer service and ability to adapt to change. Coordinates continuity of care with external healthcare organizations and facilities, including the process of obtaining authorizations for services as directed by the clinical staff. Assist with creating and faxing authorizations for DME, HH, IV antibiotics, facility transfers, and other health care needs. Participates in Patient-Centered quality improvement initiatives. Assist in mailing, sending, and gathering CMS notices from home health agencies and skilled nursing facilities. Process Denial Letters while adhering to health plan requirements, CMS, and DHCS. Updating and maintaining the most current required Health Plan templates Perform all other duties as assigned. Requirements Qualifications: High school diploma or equivalent required. 1-2 years working in a health care or other related business environment working in authorizations, medical assisting and/or medical billing services preferred. General knowledge of EZCAP preferred. General knowledge of Microsoft Office applications; Excel, Word; proficient in the use of Outlook. Completion of vocational school program in medical assisting, medical front office, or medical billing and coding preferred. Ability to create professional documents using proper grammar and punctuation. Ability to handle various situations in a professional manner, always demonstrating excellent customer service and ability to adapt to change. Ability to continually re-prioritize to meet the needs of internal and external customers throughout the workday. Willingness to work as part of a team, working collaboratively with others to achieve goals, solve problems, and meet established organizational objectives. Ability to be reliable in attendance and timeliness to work schedules. Ability to adhere to dress code, good grooming, and personal hygiene habits. Ability to maintain knowledge of and conform to company policies and procedures. The ability to always maintain strict confidentiality. Working Conditions: Standard office setting with regular use of computers and other office equipment. May involve prolonged periods of sitting and occasional light lifting. Physical Requirements: Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions of this position. This position is primarily performed in a professional office environment and requires the ability to: Frequently remain seated and stand throughout the workday while performing assigned duties. Occasionally walk, climb, bend, twist, reach forward and overhead, squat, kneel, or crawl as necessary to perform assigned duties. Occasionally lift materials weighing up to 15 pounds from floor to waist level and up to 10 pounds at waist level and above. Occasionally carry, push, pull, and transport work-related materials or equipment. Occasionally perform tasks requiring wrist position deviation, pinching, gripping, and fine motor coordination. Frequently use a computer, keyboard, mouse, telephone, and other equipment requiring repetitive hand and wrist movements. Continuously communicate effectively through talking and hearing to receive, understand, and exchange information. Possess sufficient near vision, including the ability to read at 20/20 acuity, and far vision at 20/40 acuity, and adequate color discrimination and depth perception to perform assigned duties. Work in environments where exposure to bloodborne pathogens, chemicals, airborne communicable diseases, extreme temperatures, uneven surfaces or elevations, extreme noise levels, and dust or particulate matter may be reasonably anticipated. Work in an environment where exposure to radiation is not anticipated. #J-18808-Ljbffr