Utilization Management Coordinator

Job Description

Job Description

Description:

Position Summary

The Utilization Management (UM) Coordinator is responsible for providing administrative, operational, and care coordination support to the inpatient and outpatient Utilization Management teams within Blue Zones Health, an Independent Practice Association (IPA).

This position plays an essential role in facilitating timely processing of authorization requests, coordinating communication between healthcare providers and facilities, supporting hospital discharge planning, and assisting with transitions of care to promote continuity of services and positive member outcomes.

The UM Coordinator works closely with LVNs, RNs, Medical Directors, hospital case managers, discharge planners, health plans, contracted providers, and members to ensure accurate documentation, timely communication, and efficient coordination of medically necessary services.

The ideal candidate is highly organized, detail-oriented, comfortable managing multiple priorities, and experienced in managed care operations. This position requires the ability to work independently in a fully remote environment while maintaining a strong commitment to regulatory compliance, member service, and operational excellence.

Budgeted Compensation: $25 - $31 per hour

Essential Duties and Responsibilities

1. Inpatient Utilization Management Support

•Receive, process, and track inpatient admission notifications, concurrent review requests, transfers, and discharge notifications.

•Maintain accurate inpatient census records and update member hospitalization status within the organization's utilization management system.

•Obtain and organize clinical documentation from hospitals and facilities to support timely concurrent review by licensed clinical staff.

•Monitor outstanding requests for clinical information and follow up with hospital utilization review departments and case managers.

•Assist with tracking inpatient authorization status, continued-stay reviews, and anticipated discharge dates.

•Communicate with hospital case managers, discharge planners, and internal clinical teams regarding authorization status and outstanding documentation.

•Identify cases approaching established turnaround-time deadlines and promptly escalate to the appropriate clinical staff or supervisor.

•Support coordination of inpatient transfers and post-acute care requests, including skilled nursing facilities, rehabilitation facilities, and other levels of care.

•Maintain accurate documentation of communications, notifications, and authorization-related activities.

•Support the inpatient UM team in identifying operational barriers that may delay review or discharge coordination.

2. Outpatient Utilization Management Support

•Receive, review for administrative completeness, and process routine and urgent outpatient authorization requests.

•Verify member eligibility, health plan enrollment, provider information, and applicable authorization requirements.

•Review requests for required documentation, procedure codes, diagnosis codes, and other necessary administrative information.

•Enter authorization requests into the utilization management system accurately and within established timelines.

•Obtain missing information from requesting providers and facilities to facilitate timely review.

•Route requests requiring clinical evaluation to the appropriate LVN, RN, or Medical Director.

•Prepare and distribute authorization correspondence and notifications in accordance with approved determinations and applicable regulatory requirements.

•Monitor authorization queues to identify pending, incomplete, urgent, or overdue requests.

•Respond to provider inquiries regarding authorization status, required documentation, and established processes.

•Provide cross-coverage for inpatient and outpatient UM workflows based on departmental priorities and staffing needs.

3. Transitions of Care (TOC) & Discharge Planning Support

•Provide administrative and coordination support for members transitioning from inpatient hospital settings to home, skilled nursing facilities, rehabilitation facilities, or other post-acute settings.

•Collaborate with hospital discharge planners, case managers, and internal clinical staff to facilitate timely coordination of discharge-related services.

•Assist with obtaining information regarding anticipated discharge dates, discharge destinations, and outstanding post-discharge needs.

•Coordinate administrative activities related to home health services, durable medical equipment (DME), transportation, specialty follow-up appointments, and other post-discharge services.

•Communicate with contracted providers and facilities regarding service availability, referral status, and authorization requirements.

•Assist in coordinating post-discharge appointments with primary care providers and specialists.

•Support outreach to recently discharged members to confirm discharge status, facilitate follow-up appointments, and identify administrative barriers to accessing care.

•Escalate member-reported symptoms, medication concerns, clinical needs, or barriers to safe discharge to the appropriate licensed clinical staff.

•Facilitate referrals to care management programs for members requiring additional support.

•Track completion of assigned TOC activities and document outreach attempts, successful contacts, and outstanding follow-up needs.

•Support initiatives designed to reduce avoidable hospital readmissions and improve continuity of care.

4. Provider, Facility & Member Communication

•Serve as a primary administrative point of contact for providers, hospitals, facilities, health plans, and members regarding utilization management and care coordination activities.

•Communicate professionally and effectively by telephone, secure email, fax, and approved electronic communication platforms.

•Respond to provider and facility inquiries regarding authorization requests, documentation requirements, referral processes, and service coordination.

•Assist members in understanding administrative aspects of authorizations, referrals, and accessing approved healthcare services.

•Coordinate communication between internal clinical staff and external healthcare partners to resolve outstanding requests.

•Maintain timely follow-up on pending requests and unresolved operational issues.

•Escalate clinical questions, complaints, potential quality-of-care concerns, and other matters outside the coordinator's scope to appropriate staff.

•Provide courteous, culturally sensitive, and member-centered customer service.

•Support communication with Spanish-speaking members and providers when qualified and appropriate.

5. Regulatory Compliance, Documentation & Quality

•Follow established departmental policies, standard operating procedures, and applicable regulatory requirements.

•Support compliance with CMS, Medicare Advantage, California Department of Managed Health Care (DMHC), health plan contractual requirements, and applicable NCQA standards.

•Monitor assigned authorization requests and workflows to support compliance with applicable turnaround times and notification deadlines.

•Maintain complete, accurate, and timely documentation in the organization's utilization management and care management systems.

•Ensure authorization correspondence is generated and distributed accurately using approved templates and processes.

•Protect member confidentiality and comply with HIPAA and organizational information security policies.

•Assist with audits, reporting, data validation, and quality improvement initiatives.

•Identify recurring workflow issues, documentation deficiencies, and opportunities for process improvement.

•Participate in departmental meetings, training, and operational improvement activities.

Performance Expectations & Key Performance Indicators

Performance will be evaluated based on established departmental standards, including:

•Authorization Processing Timeliness: Accurate and timely intake, entry, routing, and administrative processing of authorization requests.

•Regulatory Turnaround-Time Compliance: Effective monitoring and escalation of requests approaching applicable deadlines.

•Inpatient Census Accuracy: Timely and accurate tracking of inpatient admissions, transfers, and discharges.

•Discharge Coordination Support: Timely completion of assigned administrative activities supporting safe and efficient discharge planning.

•Transitions-of-Care Outreach: Timely completion and documentation of assigned member outreach and follow-up coordination activities.

•Documentation Quality: Accuracy, completeness, and consistency of documentation within organizational systems .

•Provider & Member Responsiveness: Timely and professional communication with providers, facilities, health plans, and members.

•Productivity & Workload Management: Ability to manage assigned work queues and meet established departmental productivity expectations.

•Team Collaboration: Effective cross-coverage and support of inpatient and outpatient UM teams.

Work Environment & Schedule

•This is a fully remote position requiring a secure, private workspace appropriate for handling protected health information.

•Reliable high-speed internet access and the ability to work within multiple electronic systems are required.

•Standard working hours are Monday through Friday, with scheduling determined by departmental operational needs.

•The position requires regular telephone and electronic communication with healthcare providers, facilities, members, and internal staff.

•Employees must be able to work independently, meet established deadlines, and maintain responsiveness during assigned work hours.

•Participation in virtual team meetings, training sessions, and quality improvement activities is required.

  Education

•High school diploma or equivalent required.

•Associate degree or additional education in healthcare administration, medical assisting, health information management, or a related field preferred.

•Medical Assistant certification or other relevant healthcare certification preferred but not required.

Required Experience

•Minimum of 2 years of experience in healthcare administration, medical office operations, utilization management, referral coordination, or managed care.

•Experience communicating with healthcare providers, facilities, and patients or health plan members.

•Familiarity with medical terminology, healthcare documentation, and authorization processes.

•Experience using electronic medical records, practice management systems, or utilization management platforms.

•Proficiency in Microsoft Office applications, including Outlook, Excel, Word, and Teams.

Preferred Qualifications

•Previous experience working within an IPA, delegated medical group, managed care organization, or health plan.

•Experience supporting inpatient and/or outpatient utilization management workflows.

•Familiarity with Medicare Advantage and managed care authorization requirements.

•Experience coordinating hospital discharges, transitions of care, or post-acute services.

•Knowledge of skilled nursing facilities, home health services, durable medical equipment, and referral processes.

•Familiarity with CMS, DMHC, and NCQA requirements related to utilization management.

•Experience working in a remote healthcare environment.

•Bilingual proficiency in English and Spanish strongly preferred.

Required Knowledge, Skills & Abilities

•Strong organizational and time-management skills with the ability to prioritize multiple tasks and deadlines.

•Excellent verbal and written communication skills.

•Ability to communicate effectively with members, physicians, hospital staff, and interdisciplinary healthcare teams.

•Strong attention to detail and accuracy in data entry and documentation.

•Knowledge of healthcare terminology, referral processes, and authorization workflows.

•Ability to recognize urgent requests and escalate time-sensitive issues appropriately.

•Strong customer service skills and a commitment to member-centered care.

•Ability to work independently and collaboratively in a fully remote environment.

•Proficiency in navigating multiple electronic systems and communication platforms.

•Ability to maintain confidentiality and handle sensitive healthcare information.

•Flexibility to support inpatient, outpatient, and transitions-of-care workflows based on operational needs.