utilization management coordinator i mso

2 weeks ago

Burlingame, California, United States North East Medical Services Full time $65,000 - $85,000 per year

The Utilization Management Coordinator I functions under the direct supervision of a physician or Registered Nurse, performing utilization management (UM) and care coordination duties for the NEMS MSO.

ESSENTIAL JOB FUNCTIONS:

  • Review daily all incoming Referral Requests and Treatment Authorization Requests for inpatient and outpatient services.
  • Process and approve authorization requests according to the NEMS MSO Authorization Grid and to established clinical guidelines.
  • Must meet the quantitative productivity standard of 250 authorizations per week for the outpatient UM Coordinator and 115 authorizations per week for the inpatient UM Coordinator.
  • For complex cases, research additional relevant clinical guidelines from different sources.
  • Responsible to prepare and present complex cases to Medical Director for review; confirm Medical Director's approval/modification/denial decision for record tracking.
  • Perform Care Coordination activities with members, families, specialists, and ancillary providers for authorized services.
  • Perform customer service for UM inquiries to Primary Care Physician, specialist, and members.
  • Stay current with DHCS regulations, Health Plan agreements, and Industry Standard guidelines applicable to healthcare programs.
  • Communicate UM related information and updates to all members of the health care team, patients, and their families.
  • Follow the appropriate turnaround timeframe for decisions and notification of members and providers.
  • Performs other job duties as required by manager/supervisor.

QUALIFICATIONS:

  • Completion of a 2-year degree or higher.
  • Knowledge of medical terminology.
  • Completion of a recognized Medical Assistant degree or certificate a plus.
  • Excellent data entry skills.
  • Working knowledge of managed-care a plus.
  • Strong communication, analytical, and problem-solving skills.
  • Knowledge of community resources and cultural needs.
  • Good organization and prioritization skills, outstanding in time management.
  • Recent experience in a clinic or outpatient setting desirable; able to perform efficiently and appropriately in a busy environment.

LANGUAGE:

  • Must be able to fluently speak, read and write English.
  • Fluent in Chinese (Cantonese and/or Mandarin) preferred.
  • Fluent in other languages is an asset.

STATUS:

  • This is an FLSA Non-exempt position.
  • This is not an OSHA high-risk position.

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