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Outpatient Utilization Management Specialist
2 months ago
Position: Outpatient Utilization Management Specialist at MedPOINT Management
Role Summary
The Outpatient Utilization Management Specialist is essential in enhancing communication between Managed Services Organizations (MSO), Independent Physician Associations (IPA), and members to guarantee seamless member care. Key responsibilities include ensuring care accessibility, confirming contractual entities, and adhering to timeliness standards. This role reports directly to the Outpatient Lead Coordinator and is overseen by the manager.
Key Responsibilities
- Process authorization requests in accordance with state and federal regulations
- Ensure data entry accuracy to reduce errors
- Confirm member benefits and eligibility upon receipt of treatment authorization requests
- Utilize authorization matrices, ancillary rosters, Delegation of Function Requests (DOFR), and/or delegation agreements for informed decision-making
- Collaborate with referral clinicians and/or medical directors for efficient processing
- Engage with medical directors to facilitate medical reviews for non-clinical medical review referrals
- Communicate with members regarding adjudication outcomes
- Reach out to providers' offices for additional required information
- Stay informed on CMS & Medi-Cal policy guidelines, including Medicare Local Coverage Determinations (LCD) vs National Coverage Determinations (NCD)
- Identify and update case management clinicians on complex care diagnoses
- Screen cases for potential California Children Services (CCS) eligible conditions
- Manage and respond to inquiries via email
- Collaborate with various departments to resolve member/provider issues
- Assist with data entry for additional requested services
- Support special projects as necessary
- Help manage a high volume of calls at the Client Support Center
- Provide support to team members with their workloads
- Regularly participate in UM team meetings
Minimum Qualifications
- High School diploma or GED equivalent
- A minimum of one year of experience in a medical office setting
- Proficient in medical terminology
- Strong command of Microsoft Office applications, especially Word and Excel
- Familiarity with EZCAP is advantageous
Skills and Competencies
- Exceptional multitasking skills in a dynamic environment
- Reliable, dependable, and accountable
- Strong customer service abilities with effective telephone communication
- Empathetic approach towards complex cases
- Self-motivated and capable of working independently
- Sharp critical thinking and problem-solving skills
