Utilization Management Coordinator

Utilization Management Coordinator

This position performs non-clinical functions for the Utilization Management process. Facilitates department workflows by supporting the clinical team with various utilization requests. Effectively and efficiently manages a diverse workload in a fast-paced and rapidly changing environment.

• Verifies eligibility and/or benefit coverage for requested services.

• Enters pre-service requests and/or authorizations into clinical system using diagnosis codes and CPT coding; verifies all necessary documentation has been submitted.

• Answers queue calls relating to UM review and pre-service status.

• Provides referrals and authorization to external providers.

• Communicates authorization status to members

• Meets specific deadlines and prioritizes assignments according to department policies, standards and needs.

• Provides information required for denial letters for members whose benefits do not cover requested services

• Supports and facilitates teamwork within the department / group and the organization.

• Participates in scheduled departmental / group meetings.

• Requests necessary clinical information to ensure requests are properly set up for clinical review in the system. Troubleshoots when a provider, type of service or appropriate level of care cannot be readily found.

• Converts clinical information obtained from providers (received via fax, phone, web, e-mail or mail) into electronic records within the system.

• Facilitates and assists in completion of appropriate documentation and provider-related forms as needed.

• Assists the Utilization Management (UM) team in daily management of incoming and outgoing documentation.

• Redirects participating providers with out-of-network requests, if needed.

• Proactively seeks and participates in ongoing training (formal and informal) in all aspects of the UM coordinator role.

• Remains responsible for updating self on ever-changing information to ensure accuracy when dealing with members and providers.

• Coordinates and manages distribution of correspondence and materials to members and providers.

• Participates in operational activities, including data collection, tracking, and analysis.

Qualifications:

• HS diploma or GED required; Associates preferred.

• A minimum of six months experience in the medical field, either in a hospital, clinical or insurance setting required.

• Prior experience with obtaining authorizations and/or benefits from a Health Plan preferred.

• Excellent keyboard and web navigation skills and ability to use a variety of electronic information processing; Proficient in the use of Microsoft programs.

• Excellent skills in time management, including ability to manage priorities and complete assignments within designated timeframes; and be self-directed in a virtual work environment.

• Ability to collaborate with a virtual team.

• Develop and manage interpersonal relationships.