UM Coordinator

Astiva Health•Orange, CA

About The Position

The UM Coordinator understands and follows Utilization Management Policies and Procedures pertaining to the referral process. This role involves processing Prior Authorization-Referral requests received from PCPs and/or Specialty Providers, responding to incoming calls and following up in a timely manner. The coordinator performs necessary research to determine satisfactory dispositions, checks voicemail promptly, and collaborates with Membership Management and Claims and Contracting Departments as needed. Key duties include documenting all applicable notes, reminders, date/time stamps, and initials involved in the referral process. The role also involves accepting calls from physicians, their office staff, and health plan inquiries regarding referral status, and performing research to track down referral packets when necessary. The UM Coordinator is expected to achieve and maintain all applicable departmental production standards and goals. When time permits, staff are expected to assist others within the department to facilitate workflow and the referral process. Additional responsibilities include verifying patient addresses in EZ-cap against the prior authorization/referral request form, recognizing health plan types and noting any shared risk or unique payors/providers, and recognizing all referral types and levels of urgency for accurate data entry within productivity standards.

Requirements

Medical Assistant (MA) certification required.
High school diploma or equivalent required.
Two years current experience in a medical office or health plan environment.
Current knowledge of medical coding and medical terminology.
Strong computer skills and proficiency in word processing.
Detail oriented, able to function under pressure and perform multi-tasks at any given time.
Excellent communication skills, verbal and written.

Nice To Haves

LVN Preferred

Responsibilities

Understands and follows Utilization Management Policies and Procedures pertaining to the referral process.
Processes Prior Authorization-Referral requests that are received from PCPs and/or Specialty Providers.
Responds to all incoming calls and/or follows up calls in a timely manner.
Performs the necessary research for determining a satisfactory disposition.
Documents all applicable notes, reminders, date/time stamps, initials etc. involved with the referral process.
Accepts calls from physicians and/or their office staff, as well as health plan inquiries regarding referral status.
Performs the necessary research (i.e., tracks down the referral packet, etc.).
Achieves and maintains all applicable departmental production standards and goals.
Assists others within the department to facilitate workflow and the referral process when time permits.
Verifies that the patient address in EZ-cap corresponds with prior authorization/referral request form.
Recognizes health plan types and makes notation of any/all shared risk or other unique payors or providers as directed.
Recognizes all referral types as well as level of urgency and performs accurate data entry within productivity standards.