Care Coordinator

Palomar Health Medical Group

88d

About The Position

The UM Care Coordinator I will coordinate with physician office staff, patients, and insurance companies to ensure that all types of insurance are verified, and services are authorized. The UM Care Coordinator I will ensure accurate, prompt, and superior service, answer phones, communicate with all departments and individuals regarding matters related to patient care, and obtain and enter accurate demographic/insurance information for all encounters including patient financial expectations. The UM Care Coordinator I will prepare referral requests for outpatient services, elective inpatient admissions, skilled nursing facility admissions, durable medical equipment (DME), and home health, utilize health plan websites to obtain benefit verification information and medical necessity criteria, to be utilized by licensed staff to determine the medical appropriateness of the requested service.

Requirements

• High School or equivalent education.
• 0-12 months in the medical field or Managed Care setting.

Nice To Haves

• Medical Administrative or Insurance Specialist Certified.
• 2 Years in healthcare setting.

Responsibilities

• Obtain necessary medical/clinical information utilizing multiple sources including use of specific medical group electronic health records.
• Accurately interpret external criteria and internal operational documents.
• Ensure medical necessity criteria selected is appropriate for the referral request being reviewed.
• Document in the referral management system actions taken on each referral processed.
• Attach corresponding documents to the referral within the referral management system in OnBase.
• Refer referral requests for review by licensed staff and Medical Directors within required turn-around times (TAT).
• Serve as a liaison to the Case Management team and assist with obtaining requested information.
• Verify member eligibility status and obtain detailed benefit coverage for service requests.
• Accurately interpret health plan benefits and apply the benefit guidelines to approve referral requests.
• Research and assist in the benefit denial process by utilizing operational documents.
• Coordinate, review, and process retrospective claims for medical care and services.
• Provide a determination for services that are appropriate for approval at the UM Care Coordinator level of review.
• Accurately complete the eMD form and forward the claim with all applicable information to the Medical Director.

What This Job Offers

• Education Level: High school or GED
• Number of Employees: 501-1,000 employees