Utilization Management (UM) Support Coordinator (Non-clinical)

Reports to:

Manager, Medical Management

Position Summary:

In charge of providing both coordination and support to utilization management processes and the Medical Management department. Will ensure processes run smoothly within the business. This position performs troubleshooting when problem situations arise and takes independent action to resolve complex issues. As needed, supports reviews for proper medical procedures and appropriate actions taken.

Job Responsibilities

• Input data into the Medical Management system to ensure timeliness of referral/authorization processing
• Verifies member benefits and eligibility upon receipt of the treatment authorization request
• Ensure timely provider and member oral and written notification of referral decisions
• Prepares denial letters for review by Medical Director or UM Nurses and distributes letters to appropriate recipients
• Prepares coordination for out-of-network cases and facilitates Single Case Agreements (SCA) processing in collaboration with Medical Directors and Leadership
• Performs coordination of benefits
• Ensures proper notification of patient facility admissions with PCP and NOMNC when applicable, ensures proper member documentation is maintained, such as CCVF’s, based upon line of business state and/or federal requirements
• Process referrals and/or calls within the department utilizing established workflows and technology platforms.
• Meets inter-rater minimum standards for core responsibilities
• Performs additional duties as assigned

Job Skills & Qualifications

• Ability to pay attention to the minute details of a project or task
• Knowledge of CPT and ICD-10 coding
• Excellent communication, organizational, and customer service skills
• Experience in the use of web-based technology and Microsoft Office applications such as Word, Excel, and PowerPoint

Required:

• High School Diploma or equivalent
• Minimum 2 years of experience working in a medical billing environment (HMO preferred)

Preferred:

• MA or Medical Billing Certificate
• Prior lead position experience
• Experience with pre-authorizations and reimbursement regulations pertaining to government programs