Utilization Management Care Coordinator

Solis Health Plans• Doral, FL, US, FL

4d•$20 - $23•Onsite

About The Position

Solis Health Plans is a new kind of Medicare Advantage Company. We provide solutions that are more transparent, connected and effective for both our members and providers. Solis was born out of a desire to provide a more personal experience throughout all levels of the healthcare journey. Our team consists of expert individuals that take pride in delivering quality service. We believe in a culture that collaborates and supports one another, and where success is interlinked and each employee is valued. The UM Care Coordinators are instrumental in helping patients receive great care with the attention and follow-up they need for optimal healthcare experiences. This requires a flexible attitude, quick thinking and a caring disposition.

Requirements

BILINGUAL IN ENGLISH AND SPANISH IS REQUIRED
Post High School graduate courses or equivalent with significant experience in healthcare related customer service position; or equivalent combination of education and experience
Excellent computer knowledge is required, including proficient knowledge of Microsoft Office
Strong decision-making and organizational skills
Excellent listening, interpersonal, verbal and written communication skills with individuals at all levels of the organization
Must be able to work with little or no supervision
Willingness and ability to function independently and as a team member
Working Knowledge of medical terminology
Ability to handle multiple functions and prioritize appropriately
Ability to meet strict deadlines
Must be patient in dealing with an elderly population and sympathetic to hearing or vision deficiencies
Ability to read, analyze, and interpret technical procedures or governmental regulations
Ability to define problems, collect data, establish facts, and draw valid conclusions
Strong decision-making, analytical skills
Must be self-motivated, organized and have excellent prioritization skills
Must be able to work well under stressful conditions
Must be able to work in fast paced environment

Nice To Haves

Insurance experience in the Medicare and managed care field is preferred
Knowledge of CMS guidelines and InterQual is preferred

Responsibilities

Scheduling UM Authorization and Determination tasks
Refers all services requiring prior authorization to UM Nurse or BH UM Nurse as appropriate
Manage determination placement
Communicate with nurses and physicians
Receives and responds to telephonic inquiries from providers regarding status of authorization requests and other questions or concerns
Guides practitioners to appropriate referral resources
Handle inbound calls and answer member and provider questions
Connect with new members via phone and email as requested
Communicate with members to determine and confirm their needs
Arrange and coordinate special equipment or therapy for at-home care
Maintain files and company information as required
Provide timely data entry referrals for continuing care as necessary
Perform benefit approvals on services, procedures, and tests that are listed on the UM Coordinator’s approval list. (These services do not require clinical judgment nor are reviewed for medical necessity. This list is reviewed as needed and at least annually for continued use by the UM Coordinator)
Process routine referral services that do not require a Prior Authorization
Ensures timely printing and mailing of pre-certification, authorization and denial letters
Appropriately documents interactions and activities into the UM electronic system
Produces reports from UM electronic system for review and analysis by appropriate Leadership team member
Assist the company care team with goal setting
Ensures compliance with all federal, state, and local regulations.
Help with member data collection including medical records, HRA, etc.
Maintain patient confidentiality
Related duties as needed