Medical Management Care Coordinator I

Santaclara Family Health Plan•San Jose, CA

67d•Onsite

About The Position

The Medical Management Care Coordinator I performs non-clinical supportive duties related to utilization management (UM) and care coordination for Santa Clara Family Health Plan (SCFHP) members. Routine supportive duties include but are not limited to data entry into system software applications, managing department telephone queues, and assisting with quality monitoring projects for both SCFHP lines of business in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, Care Coordinator Guidelines and business requirements.

Requirements

High school diploma or GED. (R)
Minimum two years of experience in a health care setting in positions requiring interaction with members and/or providers. (R)
Proficient in adapting to changing situations and efficiently alternating focus between telephone and non-telephone tasks to support department operations as dictated by business needs. (R)
Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R)
Demonstrated ability to consistently meet Key Performance Indicators by participating in and achieving the standards put forth to achieve the standard requirements of the Utilization Management Department (R)
Ability to work within an interdisciplinary team structure. (R)
Work weekends and company holidays as needed based on business and regulatory requirements. (R)
Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific UM programs. (R)
Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing. (R)
Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
Ability to maintain confidentiality. (R)
Ability to comply with all SCFHP policies and procedures. (R)
Ability to perform the job safely and with respect to others, to property and to individual safety. (R)

Nice To Haves

Knowledge of health plan benefits, process and operations related to commercial, Medi-Cal and/or Medicare programs. (D)

Responsibilities

Follow established Health Services policies and procedures and use available resources to respond to member and/or provider inquiries and resolve any concerns in an accurate, timely, respectful, professional and culturally competent manner
Collaborate with team members on improvement efforts across-departments regarding quality improvement projects, optimization of utilization management, and member satisfaction.
Develop effective and professional working relationships with internal and external stakeholders and partners. Communicate effectively with members and providers orally and in writing.
Assist in gathering and processing data for internal required reports and analysis.
Attend and actively participate in daily, weekly, and monthly departmental meetings, in-services, training and coaching sessions.
Follow UM policies and processes to the management of incoming authorization requests received through fax, mail or telephone.
Identify authorization requests for line-of-business, urgency level, type of service, and assess for complete/incomplete record submission.
Perform complete, accurate, and consistent data entry into system software applications in accordance with policies, procedures and instruction from UM management.
Answer inbound UM phone queue calls timely to assist members and/or providers regarding inquiries involving authorizations, SCFHP program services, and/or benefits.
Process written and verbal notifications of authorization determinations to members and/or providers within regulatory processing timeframes.
Perform other duties as required or assigned.