Utilization Management Coordinator I

CHPW•Seattle, WA

3d•Onsite

About The Position

The Utilization Management (UM) Coordinator I is responsible for performing administrative functions in processing UM organization determinations for services requiring authorization and hospital notification. This role utilizes knowledge of Medicare and Medicaid guidelines to facilitate and comply with UM processes, including data entry of authorization requests, eligibility verification, benefit determinations, timely letter fulfillment, and support to UM clinical staff.

Requirements

Associate degree, or an equivalent combination of education and highly relevant experience.
At least one (1) year of customer service experience.
Working experience in a Healthcare setting.
Working experience in a Managed Care setting.
Knowledgeable of medical terminology and healthcare processes.
Knowledgeable of Washington Apple Health and Medicare Advantage Plans.
Solid analytical skills and the ability to interpret, evaluate and formulate action plans based upon data.
Knowledge of care management workflow systems.
Effective verbal and written communication skills.
Able to communicate with and collaborate effectively with physicians and allied health care providers.
Flexibility and willingness to work in a matrix-management environment.
Demonstrated organizational, time management, and project management skills.
Ability to multi-task and deal with complex assignments on a frequent basis.
Demonstrated proficiency and experience with Microsoft Office products.
Ability to work independently.
Collaborate with others in a respectful manner and ability to maintain confidentiality.
Perform all functions of the job with accuracy, attention to detail and within established timeframes.
Complete and successfully pass a criminal background check.
Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.
Vaccination requirement (CHPW offers a process for medical or religious exemptions)

Nice To Haves

Customer service experience, preferred.
Working experience in a Healthcare setting, preferred.
Working experience in a Managed Care setting, preferred.
Knowledgeable of medical terminology and healthcare processes, preferred.
Knowledgeable of Washington Apple Health and Medicare Advantage Plans, preferred.

Responsibilities

Performs data entry for all referral, prior authorizations and hospital notifications; attaches and/or includes clinical documents as needed.
Utilizes knowledge to determine appropriate CPT, HCPC, ICD-10 codes using CMS, NCQA and HCA criteria.
Researches and validates benefit and prior authorization requirements to determine appropriate course of action within the Care Management system.
Reviews, corrects, and approves authorization requests via the web portal; determines appropriate level of complexity and refers cases requiring clinical review to a nurse reviewer.
Reviews completed denial letters for accuracy and adherence to compliance deadlines.
Edits and proofreads content for appropriate medical terminology and MCG criteria.
Ensures letters are mailed within established timeframes.
Accurately applies policies & procedures, benefit and eligibility standards to all incoming requests.
Conducts research, validates data, and responds to complex inquiries from multiple sources, including but not limited to members, nurses, medical providers, customer service, operations, appeals, case management and care coordination.
Escalating issues as needed.
Reporting to work on time and for all scheduled shifts is essential to this position.
Other duties as assigned.