UM Coordinator I

Community Health Center Network•San Leandro, CA

7d•$0 - $29

About The Position

The UM Coordinator I provides primarily administrative support for utilization management and case management and delivers health care support services to CHCN members, providers, and staff. The role processes prior authorization requests in compliance with applicable guidelines, responds to questions about referrals, benefits, eligibility, and authorization status, and communicates with members, providers, health plan staff, and other relevant organizations. It also supports authorization documentation, turnaround-time requirements, denial and approval communications, claims review, provider education, and the protection of confidential health information.

Requirements

One to two years of prior healthcare experience in medical records, medical billing, or a medical office.
At least one year of experience with state and federal insurance programs.
Current Medical Assistant certification, a California Pharmacy Technician license, or equivalent healthcare-field experience with familiarity with medical terminology and concepts.
High school diploma or GED.
Proficiency in CPT/HCPCS and ICD-10 codes.
Strong written and verbal communication skills, including English grammar, composition, editing, and proofreading.
Detail orientation and problem-solving ability.
Strong organization, time management, and multitasking skills.
Ability to work with detailed and varied data while maintaining confidentiality.
Ability to work well with others and maintain a courteous, patient, and helpful attitude.
Basic understanding of health plan and CHCN policies and procedures.
Organized, self-managed approach and willingness to learn.

Nice To Haves

Experience in an HMO, IPA, or managed care setting.

Responsibilities

Research medical utilization management requests using health plan evidence of coverage, CHCN policies and procedures, healthcare resources, and state eligibility verification systems.
Refer cases to UM nurses, case managers, and the Medical Director for clinical review and potential denial or modification.
Provide administrative and clerical support for utilization management and case management activities.
Respond to members’ and providers’ questions and resolve issues related to referrals, benefits, eligibility, authorization status, and modification requests.
Protect the privacy and security of protected health information in accordance with CHCN and health plan policies and HIPAA requirements.
Call members and providers according to utilization management and case management protocols.
Communicate with health plan UM staff, providers, inpatient staff, and relevant government entities, including California Children’s Services.
Enter required prior authorization data accurately and promptly in EZ-CAP or another selected database.
Follow policies, standards, and regulations to meet turnaround-time requirements for authorizations and delivery of denial or approval letters.
Compose denial letters in accordance with decisions made by UM nurses or the Medical Director.
Coordinate activities with UM and case management colleagues and other CHCN staff.
Attend and participate in required meetings.
Coordinate inquiries from Customer Care regarding provider authorization questions.
Work with Provider Relations on ancillary updates for out-of-network providers and contract negotiation efforts through the LOA process.
Verify authorization status to support review of pended and aging claims.
Provide timely, professional education to CHCN clinic staff, ancillary providers, and hospital facilities, and escalate issues to the UM Supervisor.
Maintain regular and reliable attendance, current knowledge of CHCN-managed lines of business, and compliance with turnaround-time mandates.
Support CHCN's general organizational roles, including fostering trust and cooperation, maintaining confidentiality, participating in decision-making and required meetings, applying CHCN values, and taking part in outreach, advocacy, or ad hoc committees as requested.