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Outpatient Utilization Management Coordinator II
2 months ago
Job Overview
The Outpatient Utilization Management Coordinator serves as the primary liaison between the Outpatient Utilization Management (UM) team and Health Plan representatives. This position is responsible for managing referral requests directed to Health Plans, including but not limited to tertiary care, durable medical equipment, and pharmacy services, from the initial provider submission to the final resolution provided by the Health Plan.
Key Responsibilities
- Facilitates communication with Outpatient UM nurses and coordinators to determine Health Plan delegated decisions.
- Completes and submits Health Plan service request forms for decision-making.
- Ensures that all requests are comprehensive, containing necessary clinical and member information for review.
- Maintains compliance with CMS and DMHC regulations regarding timeliness of requests.
- Engages with provider offices to gather additional member information as required.
- Conducts outreach to Health Plans for updates on pending requests.
- Records authorization statuses and documents Health Plan decisions in the EZ CAP database.
- Provides assistance to the Client Support Center with a high volume of inquiries as needed.
- Collaborates with team members to manage workload effectively.
- Participates in regular UM team meetings.
Qualifications
- High School diploma or GED equivalent.
- Minimum of 1 year of experience in a healthcare setting.
- Familiarity with medical terminology.
- Proficient in Microsoft Office applications, particularly Word and Excel.
- Experience with EZ CAP is advantageous.
Skills and Abilities
- Exceptional customer service skills with strong telephone communication.
- Ability to manage multiple tasks while adapting to a dynamic work environment.
- Excellent verbal and written communication skills.
