UM Coordinator

Advanced Medical Management•Long Beach, CA

15h•$23 - $27•Onsite

About The Position

The Utilization Management (UM) Coordinator is responsible for coordinating prior authorization requests, processing referrals, documenting case activity, and supporting timely utilization review activities using the EZCAP Authorization System. The coordinator ensures compliance with CMS, DHCS, NCQA, and contracted health plan requirements while maintaining excellent customer service to providers, members, and internal departments. The UM Coordinator serves as the first point of contact for authorization requests and works closely with nurses, medical directors, case managers, provider offices, and health plans to ensure timely and accurate processing of requests.

Requirements

High School Diploma or GED required
Minimum 1 year in healthcare
Knowledge of medical terminology
Knowledge of ICD-10 diagnosis coding
Knowledge of CPT/HCPCS procedure coding
Knowledge of prior authorization processes
Knowledge of Medicare Advantage
Knowledge of Managed Care operations
Knowledge of HIPAA regulations
Knowledge of CMS regulations
Knowledge of NCQA standards
Excellent communication skills
Strong organizational skills
Time management
Attention to detail
Data entry accuracy
Customer service
Critical thinking
Multitasking
Problem solving
Ability to prioritize urgent work
Experience with Microsoft Outlook
Experience with Microsoft Word
Experience with Microsoft Excel
Experience with Adobe Acrobat
Experience with Electronic Fax Systems
Experience with Electronic Health Records (EHR)
Experience with Health Plan Provider Portals
Meet departmental productivity goals.
Maintain a quality score of 95% or higher.
Process authorizations within regulatory turnaround times.
Accurately document all authorization activities.
Follow all departmental policies and workflows.
Maintain confidentiality of Protected Health Information (PHI).
Demonstrate professionalism with providers, members, and coworkers.

Nice To Haves

Associate degree preferred
Prior authorization experience preferred
Managed care experience preferred
Medical office experience preferred
Health plan experience preferred
Knowledge of EZCAP preferred
Experience with EZCAP Authorization System (preferred)

Responsibilities

Receive and process prior authorization requests through EZCAP.
Verify member eligibility and health plan benefits.
Verify provider participation and network status.
Determine whether requests qualify for auto-approval.
Create new authorization records in EZCAP.
Enter accurate clinical and demographic information.
Assign requests to the appropriate review queue.
Prioritize urgent and expedited requests according to CMS requirements.
Maintain authorization documentation throughout the review process.
Process duplicate and corrected authorization requests.
Create and update authorization cases in EZCAP.
Document all provider communications in EZCAP.
Upload supporting medical records to EZCAP.
Scan and attach incoming documentation in EZCAP.
Monitor pending authorization queues in EZCAP.
Update authorization status throughout the review process in EZCAP.
Route cases to UM Nurses and Medical Directors in EZCAP.
Complete authorization closure after determination in EZCAP.
Document letter mailing information in EZCAP.
Verify authorization history in EZCAP.
Receive incoming provider telephone calls.
Respond to fax and portal authorization requests.
Obtain missing clinical documentation.
Notify providers of additional information requests.
Communicate authorization determinations.
Escalate clinical questions to UM Nurses.
Coordinate with provider offices regarding duplicate requests.
Accurately document date and time of request, source of request, clinical information received, carve-out determination source, communication attempts, fax confirmations, telephone conversations, medical record receipt, provider follow-up, and authorization status changes.
Maintain compliance with CMS Medicare Advantage regulations, NCQA Utilization Management Standards, DHCS Managed Care requirements, Knox-Keene Act requirements, Health plan contractual requirements, Organization UM Policies and Procedures, and HIPAA Privacy and Security requirements.
Monitor authorization turnaround times including urgent requests, standard requests, additional information requests, extension notifications, pending authorizations, and escalations approaching regulatory deadlines.
Maintain complete authorization documentation.
Follow departmental workflows.
Meet production standards.
Meet quality standards.
Participate in internal audits.
Correct identified documentation errors.
Attend required training sessions.
Assist with audit preparation.
Review incoming authorization queue daily.
Process fax requests daily.
Process portal requests daily.
Monitor urgent authorization requests daily.
Follow up on pending cases daily.
Upload clinical documentation daily.
Document provider communication daily.
Monitor worklists daily.
Assist nurses with non-clinical tasks.
Complete assigned production goals daily.