Utilization Management Coordinator

3 weeks ago

Downers Grove, United States Duly Health and Care Full time
Overview

Good enough isn't for us. Duly Health and Care's team members show up every day driven to exceed expectations. We see and support the remarkable in every person within and beyond the walls of our work.

Duly Health and Care works to understand what matters most to you. We recruit and retain team members who share a relentless passion and pride for helping others live happier and healthier lives. We invest in helping our team members develop their talents in a way that is rich in personal meaning. We invite you to join us, fulfill your purpose and make your mark

Holistic benefits designed to help our team members flourish in all aspects of their lives, including:
  • Comprehensive medical and prescription drug benefits that include medical coverage at 100% (after deductible) when utilizing a Duly provider.
  • $5,250 Tuition Reimbursement per year.
  • 40 hours paid volunteer time off.
  • A culture committed to Diversity, Equity, and Inclusion (DEI) and Social Impact
  • 12 Weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members.
  • 401(k) Match
  • Profit-sharing program
Are you ready to challenge the expected to deliver the extraordinary?

The Utilization Management Specialist is responsible for processing referrals and benefit determinations for capitated health plans. The UM Specialist works in collaboration with the Clinical Services Team, Manager, Medical Director and Providers to ensure that referrals are completed in accordance with Boncura Policies and Procedures.

Responsibilities

The Journeys and Adventures that Await:
  • Process referrals in accordance to Boncura Policy /Procedures and health plan requirements. This includes checking eligibility, verifying benefits, verifying medical necessity, and knowledge of referral networks.
  • Contacts health plans for referrals/ pre-certifications that require health plan approval.
  • Applies MCG guidelines, Medical Group Guidelines and CMS coverage determinations to referral requests as appropriate.
  • Ensures referrals are approved within network as medically appropriate.
  • Reviews referrals not meeting medical group criteria with the Medical Directors as needed.
  • Initiates the processing of denials in accordance with health plan and regulatory requirements under the direction of the Manager, Care Management and Medical Director.
  • Interacts in a professional manner with providers, patients, physicians, and staff by demonstrating respect not limited to communications via telephone, E-mail, My Chart or Staff Message.
  • Act as a resource for the Clinical Services Department, physicians, providers, patients and work colleagues.
  • Assist with submission of health plan reporting to ensure health plan compliance.
  • Ability to utilize resources and problem solving skills to achieve resolution when addressing questions/issues from patients, providers, and staff.
  • Maintain confidentiality in compliance with HIPPA
  • Ability to identify and report problems that need to be escalated to the Utilization Management Supervisor/Manager
  • Demonstrates a positive attitude and has the ability to adapt with change.
  • Performs other responsibilities and duties as assigned.
Qualifications

The Experiences You Bring:

KNOWLEDGE SKILLS AND ABILITIES:
  • Proficient with Medical Terminology
  • Proficient in Microsoft Office
  • Prior EPIC EHR experience a plus
  • Data Entry sills of 30+ wpm required
  • Ability to prioritize work responsibilities
EDUCATION and / or CERTIFICATION/LICENSURE:
  • Associate Degree Preferred
  • Medical Terminology, Coding Experience Desired
EXPERIENCE:
  • 2+ years of experience in utilization management in the health plan or medical group environment
  • Experience Applying MCG Guidelines (Formerly Milliman Care Guidelines)
  • Capitated Referral Experience
  • Medical Assistant or Health Plan Experience Preferred

  • Utilization Management Coordinator

    1 week ago

    Downers Grove, United States Duly Healthcare Full time

    Overview Good enough isn’t for us. Duly Health and Care’s team members show up every day driven to exceed expectations. We see and support the remarkable in every person within and beyond the walls of our work. Duly Health and Care works to understand what matters most to you. We recruit and retain team members who share a relentless passion and pride...

  • UTILIZATION MANAGEMENT COORDINATOR

    2 weeks ago

    Downers Grove, IL 60516, USA, United States Dupage Medical Group Full time

    OverviewGood enough isn't for us. Duly Health and Care's team members show up every day driven to exceed expectations. We see and support the remarkable in every person within and beyond the walls of our work.Duly Health and Care works to understand what matters most to you. We recruit and retain team members who share a relentless passion and pride for...

  • Case Management Coordinator

    2 days ago

    Downers Grove, United States Duly Healthcare Full time

    Overview Case Management Coordinator - Full-Time, 40 hours per week Good enough isn’t for us. Duly Health and Care’s team members show up every day driven to exceed expectations. We see and support the remarkable in every person within and beyond the walls of our work. Duly Health and Care works to understand what matters most to you. We recruit and...

  • Case Management Coordinator

    1 week ago

    Downers Grove, United States Duly Health and Care Full time

    OverviewCase Management Coordinator - Full-Time, 40 hours per week Good enough isn't for us. Duly Health and Care's team members show up every day driven to exceed expectations. We see and support the remarkable in every person within and beyond the walls of our work. Duly Health and Care works to understand what matters most to you. We recruit and retain...

  • Utilization Specialist, PRN

    2 weeks ago

    Downers Grove, United States Dupage Medical Group Full time

    Overview Utilization Management Specialist, Non-RN * PRN * Hours - Day/Afternoon; Must be willing to work 1-2 days per week and assist in covering vacations during winter/summer break. * Remote 75% - Will require working on-site (Downers Grove) on occasion for meetings, trainings, and to assist in rotating schedule. The Utilization Management Specialist...

  • Relationship Manager

    4 weeks ago

    Downers Grove, United States Apollon Wealth Management Full time

    Job DescriptionJob DescriptionRelationship ManagerReports to: Director of Practice Management  Status: ExemptApollon Wealth Management is looking for a driven Relationship Manager to become a valuable member of our team. Our ideal candidate will play a crucial role in maintaining smooth day-to-day operations within the organization.  Responsibilities:...

  • Bcbs Hmo Coordinator

    4 days ago

    Downers Grove, United States Duly Health and Care Full time

    Overview: **Job Title: BCBS HMO Coordinator** **Location**: Flexible (Remote options available) **Company Overview**: At Duly Health and Care, we're dedicated to revolutionizing healthcare delivery through innovative solutions and collaborative partnerships. As a leading provider in the industry, we strive to empower individuals and communities to achieve...

  • Payroll Coordinator

    2 weeks ago

    Downers Grove, United States Dupage Medical Group Full time

    Overview Good enough isn't for us. Duly Health and Care's team members show up every day driven to exceed expectations. We see and support the remarkable in every person within and beyond the walls of our work. Duly Health and Care works to understand what matters most to you. We recruit and retain team members who share a relentless passion and pride for...

  • Patient Navigation Coordinator

    1 week ago

    Downers Grove, United States Duly Health and Care Full time

    Overview: **Patient Navigation Coordinator**: - Full-Time, 40 hours per week. - Monday-Friday; Hours will vary. - Must be willing to travel on-site to Downers Grove, as needed. The Patient Navigation Coordinator is the key link to patients. This individual will coordinate with home paramedic teams in tracking visit requests, working closely with process...

  • Utilization Specialist, PRN

    3 weeks ago

    Downers Grove, Illinois, United States Duly Health and Care Full time

    Overview: Utilization Management Specialist, Non-RN PRN Hours - Day/Afternoon; Must be willing to work 1-2 days per week and assist in covering vacations during winter/summer break. Remote 75% - Will require working on-site (Downers Grove) on occasion for meetings, trainings, and to assist in rotating schedule. The Utilization Management Specialist is...

  • Account Manager I

    1 week ago

    Downers Grove, United States Onsite Management Group Full time

    Job Description Job Description OMG, LLC is a first class, service oriented organization that delivers value and excellence to our customers while enhancing the community. As such, we strive to demonstrate the following: Excellence in all we do; “Can do” attitude; Teamwork; Openness in communication; Honesty, Integrity and Candor; Positive attitude;...

  • Account Manager I

    3 weeks ago

    Downers Grove, United States Onsite Management Group Full time

    Job DescriptionJob DescriptionOMG, LLC is a first class, service oriented organization that delivers value and excellence to our customers while enhancing the community. As such, we strive to demonstrate the following: Excellence in all we do; “Can do” attitude; Teamwork; Openness in communication; Honesty, Integrity and Candor; Positive attitude;...

  • Product and Contracting Manager

    4 weeks ago

    Downers Grove, United States Abercrombie & Kent Destination Management Full time

    Position SummaryAs the Product and Contracting Manager for the USA & Canada DMC, you will oversee all facets of product development and contracting. This includes spearheading product and destination enhancements, managing contracts and supplier relationships, and nurturing the growth of the product team. Your role is pivotal in aligning these functions with...

  • Pm Unassigned Makeup and Packaging Utility

    4 days ago

    Downers Grove, United States Campbell Soup Company Full time

    Since 1869 we've connected people through food they love. Our history was created by remarkable people, ideas, and innovations. It serves as inspiration and foundation for our future success. We’re proud to be stewards of amazing brands that people trust. Our portfolio includes the iconic Campbell’s brand, as well as Michael Angelo’s, noosa, Pace,...

  • Contract Coordinator

    4 days ago

    Downers Grove, United States Duly Health and Care Full time

    Overview: **Job Title: Payor Contract Coordinator** **Location**: Flexible (Remote options available) At Duly Health and Care, we're dedicated to revolutionizing healthcare delivery through innovative solutions and collaborative partnerships. As a leading provider in the industry, we strive to empower individuals and communities to achieve optimal health...

  • Construction Coordinator

    3 weeks ago

    Downers Grove, United States Unlimited Fire Restoration Full time

    Job DescriptionJob DescriptionUnlimited Fire Restoration is a construction company located in Downer's Grove IL. We focus on residential repairs after fires, floods, water damage, and weather related damage. We work with insurance providers to ensure a smooth repair process for home owners. An ideal candidate for our coordinator position will be...

  • Project Manager

    3 weeks ago

    Downers Grove, United States Duly Healthcare Full time

    Overview Good enough isn’t for us. Duly Health and Care’s team members show up every day driven to exceed expectations. We see and support the remarkable in every person within and beyond the walls of our work. Duly Health and Care works to understand what matters most to you. We recruit and retain team members who share a relentless passion and pride...

  • Customer Care Coordinator

    4 weeks ago

    Downers Grove, Illinois, United States Penn Foster Full time

    Customer Care Coordinator The Company Zurn Elkay Water Solutions Corporation is a thriving, values-driven company focused on doing the right things.Named by Newsweek as One of America's Most Responsible Companies and an Energage USA Top Workplace, at Zurn Elkay Water Solutions Corporation, we never forget that our people are at the center of what makes us...

  • Special Projects Coordinator

    7 days ago

    Downers Grove, United States Illinois Tollway Full time

    **Position Overview**: **Position **Overview** The Illinois Tollway is dedicated to providing and promoting a safe and efficient system of highways while ensuring the highest possible level of service to our customers. Whether it's I-PASS, the _Move _Illinois _Program, open road tolling or keeping you safe with our H.E.L.P. trucks, we are committed to...

  • BCBS HMO Coordinator

    3 days ago

    Downers Grove, Illinois, United States Duly Health and Care Full time

    Overview: Job Title: BCBS HMO Coordinator   Location: Flexible (Remote options available)   Company Overview: At Duly Health and Care, we're dedicated to revolutionizing healthcare delivery through innovative solutions and collaborative partnerships. As a leading provider in the industry, we strive to empower individuals and communities to achieve...