Supports utilization management operations by processing routine and urgent treatment authorizations, reviewing referrals, verifying eligibility, benefits, provider and facility status, and meeting health plan turnaround standards. The coordinator attaches clinical documentation, contacts providers for clarification, maintains confidentiality, handles provider and internal calls, and reports issues to UM leadership. The role requires healthcare authorization or referral experience, managed care knowledge, medical coding terminology, strong organization, and proficiency with Microsoft applications.
The Utilization Management Coordinator is responsible for supporting clinical, management, and client activities, comprising the UM Program. The Utilization Management Coordinator understands all UM processes such as pre-authorizations, retro reviews, Division of Financial Responsibilities and Health Plan contracts. The UM Coordinator will ensure we are processing quality referrals in a timely manner meeting the health plan standards.
Our Values:
- Put Patients First
- Empower Entrepreneurial Provider and Care Teams
- Operate with Integrity & Excellence
- Be Innovative
- Work As One Team
What You'll Do
- Comply with UM policies and procedures. Annual review of selected UM policies.
- Read and understand NMM UM Customer Service Policy and Procedures
- Process Routine & Urgent treatment authorization requests according to the NMM Policy & Procedure Manual based on UM Level 1 review process.
- Assist with attaching incoming notes to appropriate authorizations
- Move referrals coming back from eligibility and or benefits to the correct queue for review
- Accurately review, screen and process daily assigned UM referrals (avg 150-250) in accordance with IPA and health plan TAT guidelines
- Responsible for verification to include but not limited to: benefit matrix through DOFR, eligibility, provider status (contracted/non-contracted), carved out and others.
- Contact providers office as needed for clarification, notes or redirections
- Verify that facilities are contracted and or a CMS approved facility when required.
- Attend to provider and interdepartmental calls in accordance with exceptional customer service
- Reports to UM Lead 3 on activities or problems occurring throughout the day.
- Maintains strictest confidentiality at all times.
- Maintain good relationships with health plans and medical directors and external contacts.
- Team skills, assist others as needed in order to comply with TAT.
- Other duties as assigned
Qualifications
- High School Graduate, Bachelor's in Healthcare Administration is a plus
- Experience with authorizations or referrals in healthcare
- A minimum of two years experienced in managed care environment to include but not limited to an IPA or MSO preferred
- Knowledge of medical terminology, RVS, CPT, HPCS, ICD-9 codes
- Proficient with Microsoft applications
- Good organizational skills, verbal and written communication skills
- Ability to multitask and problem solve in a fast pace work environment
- Punctuality and detail-oriented
- Ability to follow directions and perform work independently according to department standards
- Must be a strong team player and have excellent attendance record
Environmental Job Requirements and Working Conditions
- This is a remote position. Candidates must reside in California.
- This position will typically work Monday - Friday from 8:00 am to 5:00 pm. There may be up to 1 hour of voluntary OT per day.
- The target pay range for this role is $22.00 - $24.00 per hour. This salary range represents our national target range for this role
Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at [email protected] to request an accommodation.
Additional Information:
The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
About
Astrana Health (NASDAQ: ASTH) is a physician-centric, technology-powered healthcare management company. We are building and operating a novel, integrated, value-based healthcare delivery platform to empower our physicians to provide the highest quality of end-to-end care for their patients in a cost-effective manner. Our mission is to combine our clinical experience, best-in-class delivery network, and technological expertise to improve patient outcomes, increase access to healthcare, and make the US healthcare system more efficient. Our platform currently empowers over 20,000 physicians to provide care for over 1.7 million patients nationwide. Our rapid growth and unique position at the intersection of all major healthcare stakeholders (payer, provider, and patient) gives us an unparalleled opportunity to combine clinical and technological expertise to improve patient outcomes, increase access to quality healthcare, and reduce the waste in the US healthcare system.
Astrana Health, Inc. Alhambra, California, USA Office
Alhambra, CA, United States
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