Care Coordination and Utilization Management Specialist

2 weeks ago

Belle Glade Florida, United States Health Care District of Palm Beach County Full time

Overview:
In this pivotal role, you will oversee the preparation and management of cases within the utilization review framework. Acting as a primary liaison for healthcare providers, patients, and various medical professionals, you will ensure the comprehensive collection and processing of essential patient, provider, and facility data necessary for utilization review. Your responsibilities will encompass data entry, outreach to providers for additional clinical details, and the coordination of referrals to case management.

Your role will also involve essential administrative tasks, including managing documentation, data entry, provider engagement regarding claims, and responding to inquiries via phone.

This position focuses on nonclinical functions within the utilization review team, without the requirement to interpret clinical data, including the non-certification of requests.


Key Responsibilities:

Core Functions:
Prioritize and manage tasks received from nurse Utilization Reviewers.

Responsibilities may include, but are not limited to:
- Assisting in the transmission of initial, concurrent, or discharge reviews to insurance providers.
- Documenting information exchanged via phone or fax from insurance companies into electronic health records (EHR).
- Managing phone communications and faxing clinical information.


- Processing incoming faxes, scanning documents, and performing other clerical duties as necessary to support Utilization Management activities.

Ensure accuracy in task completion, including correct formatting, grammar, punctuation, and spelling.

Maintain communication regarding task progress and completion with Utilization Review nurses.

Document interactions with internal and external providers in the EHR.

Notify team members of denials and potential denials to facilitate appropriate actions by the Utilization Review nurse.

Respond to insurance inquiries for clinical reviews and EHR notifications within designated timeframes.

Contact Utilization Review nurses when reviews lack documentation.

Assist in verifying authorized lengths of stay by monitoring approved days, including calling or faxing discharge dates and entering approved lengths of stay into the EHR.

Generate and submit EHR reports tailored to third-party payers.


The Utilization Management Assistant is responsible for maintaining departmental productivity and quality metrics while ensuring compliance with regulatory and departmental standards.

Adhere to all HIPAA regulations when handling protected health information (PHI) for internal and external providers.

This includes verifying phone and fax numbers, confirming receipt, and ensuring proper identification before sharing sensitive information.

Maintain regular communication with Utilization Review Specialists, Denial Specialist Nurses, Utilization Management Team Leaders, and Patient Access Services.

Assist with documentation in various departmental databases.

Conduct audits, generate, and review reports pertinent to Utilization Management as requested to ensure data accuracy and gather statistics for reporting.

Other tasks and assignments as required.

Specific Duties and Responsibilities for Care Coordination:

Stay informed about value-based programs to develop educational initiatives for provider engagement and implementation.

Collaborate with Operations and relevant departments to formulate action plans aimed at enhancing value-based program performance.

Utilize modern computer applications to create, maintain, and update records, reports, charts, and files (e.g., Microsoft Office, Epic, Tableau, Provider Portals).

Manage and update the departmental filing system for consistency, including retrieving files, records, reports, and charts as needed.


Assist in reviewing medical records and documents, abstracting clinical data for HEDIS reporting, achieving daily goals, and uploading information to payer portals.

Document findings in relevant HEDIS databases, spreadsheets, and designated cloud-based platforms.

Obtain monthly payer rosters and organize them in corresponding electronic files. Complete discharge data and coordinate patient outreach for follow-up care.

Participate actively in departmental training and meetings.

Meet regularly with Operations to discuss value-based contract performance and provide recommendations for best practices.

Engage monthly with health plans to review performance metrics related to shared savings contracts and incentive programs.

Collaborate with the Quality Assurance department on incentive programs for each health plan.

Develop well-documented Excel-based models and spreadsheets to evaluate historical trends.

Communicate effectively with insurance carriers and internal departments to build strong relationships.

Work collaboratively with all health plans and internal staff, supporting operational departments to enhance population health performance and achieve quality incentives.

Qualifications:

Education:
Bachelor's Degree preferred; a high school diploma or G.E.D. is required, or Medical Assistant Certification acceptable in lieu of diploma or G.E.D.

Experience:
Minimum of 1 year in a hospital or insurance setting.

Basic understanding of medical terminology.

Exceptional time-management and multitasking abilities.

Ability to thrive in a dynamic environment.

Demonstrates a strong customer focus and commitment to service excellence.

Proficient computer skills.

Basic knowledge of Microsoft Word and Excel.

Must be approachable, courteous, and possess a strong work ethic that aligns with the company's culture.

Excellent written and verbal communication skills.

Licensure:
A valid Florida driver's license is required.

Training:
Proficiency in Microsoft applications is required, with advanced knowledge of Microsoft Excel, including spreadsheet creation and utilization of its functions.


The Health Care District of Palm Beach County is proud to be an Equal Opportunity Employer and Drug-Free Workplace.

We embrace diversity and 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.

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