Review and process referral and treatment authorization requests for inpatient and outpatient services, approve per authorization grid and clinical guidelines, meet productivity targets, research complex cases for Medical Director review, perform care coordination and customer service, stay current with DHCS and Health Plan requirements, and communicate decisions to members and providers.
The Utilization Management Coordinator I functions under the direct supervision of a physician or Registered Nurse, performing utilization management (UM) and care coordination duties for the NEMS MSO.
ESSENTIAL JOB FUNCTIONS:
- Review daily all incoming Referral Requests and Treatment Authorization Requests for inpatient and outpatient services.
- Process and approve authorization requests according to the NEMS MSO Authorization Grid and to established clinical guidelines.
- Must meet the quantitative productivity standard of 250 authorizations per week for the outpatient UM Coordinator and 115 authorizations per week for the inpatient UM Coordinator.
- For complex cases, research additional relevant clinical guidelines from different sources.
- Responsible to prepare and present complex cases to Medical Director for review; confirm Medical Director’s approval/modification/denial decision for record tracking.
- Perform Care Coordination activities with members, families, specialists, and ancillary providers for authorized services.
- Perform customer service for UM inquiries to Primary Care Physician, specialist, and members.
- Stay current with DHCS regulations, Health Plan agreements, and Industry Standard guidelines applicable to healthcare programs.
- Communicate UM related information and updates to all members of the health care team, patients, and their families.
- Follow the appropriate turnaround timeframe for decisions and notification of members and providers.
- Performs other job duties as required by manager/supervisor.
Qualifications
- Completion of a 2-year degree or higher.
- Knowledge of medical terminology.
- Completion of a recognized Medical Assistant degree or certificate a plus.
- Excellent data entry skills.
- Working knowledge of managed-care a plus.
- Strong communication, analytical, and problem-solving skills.
- Knowledge of community resources and cultural needs.
- Good organization and prioritization skills, outstanding in time management.
- Recent experience in a clinic or outpatient setting desirable; able to perform efficiently and appropriately in a busy environment.
LANGUAGE:
- Must be able to fluently speak, read and write English.
- Fluent in Chinese (Cantonese and/or Mandarin) preferred.
- Fluent in other languages is an asset.
STATUS:
- This is an FLSA Non-exempt position.
- This is not an OSHA high-risk position.
- This is a Full Time position.
NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
NEMS BENEFITS: Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).
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