Utilization Management Coordinator

Job Details Location: Burlingame, CA 94010 Salary Range: $39.69 - $45.10 hourly Overview The Utilization Management Coordinator II functions under the direct supervision of a physician or Registered Nurse performing utilization management (UM) and care coordination duties for the NEMS MSO. The UM Coordinator II will also provide basic training to the junior UM Coordinators. ESSENTIAL JOB FUNCTIONS Responsible to review Referral Requests and Treatment Authorization Requests received daily; process and approve authorization requests according to the NEMS MSO Authorization Grid and established clinical guidelines. Provide guidance to junior UM Coordinators during research of additional clinical guidelines from different sources for complex cases. Responsible to lead the junior UM Coordinators to prepare and present complex cases to Medical Director for review and ensure follow up activities. Responsible for reviewing the confirmed MD approval/modification/denial decision and notes for record tracking purposes. Responsible to prepare UM Notice of Action (NOA) to provider and member for UM denial decision per AB1455 turn-around-time requirement. Responsible for preparing UM statistical reports and submit to health plans per contract requirement. Perform Care Coordination activities with members, families, specialists, and ancillary providers for authorized services. Perform case investigation for member and/or provider complaints and appeals related to UM denials, and report findings to Health Plan. Provide transition of care services to members who are discharged from the hospital. Perform customer services for UM inquires to PCP, specialist, and members. Stay current with DHCS regulations, Health Plan agreements, and Industry Standard guidelines applicable to healthcare programs. Communicate with Health Plan for clarification about clinical guidelines for covered/uncovered benefits. Communicate UM related information and updates to all members of the health care team, patients, and their families. Follows the appropriate turnaround timeframe for decisions and notification of members and providers. Performs other job duties as required by manager/supervisor. QUALIFICATIONS BS/BA Degree in Health Science or General Education highly preferred. Minimum of one year of experience in utilization management required. Recent experience in a clinic or outpatient setting desirable; able to perform efficiently and appropriately in a busy environment. Current Medical Assistant Certification or California Pharmacy Technician License or equivalent experience in a health care field is a plus. Knowledge of medical terminology is a must. Strong communication, analytical, and problem‑solving skills. Knowledge of community resources and cultural needs. Good organization and prioritization skills, outstanding in time management. LANGUAGE Must be able to fluently speak, read and write English. Fluent in Chinese (Cantonese and/or Mandarin) preferred. Fluent in other languages is an asset. STATUS This is an FLSA Non‑exempt position. This is not an OSHA high‑risk position. This is a full‑time position. NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records. BENEFITS Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k). #J-18808-Ljbffr