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UM Coord II at ConcertoHealth
Aliso Viejo, CA, US

 

Job Details

Description

JOB SUMMARY 
The UM Coordinator II position is a liaison between the patient and specialty providers and other ancillary services to ensure benefit requirements are met by requesting authorizations. The UM Coordinator II will keep the patient and providers informed during the process. 


ESSENTIAL DUTIES AND RESPONSIBILITIES 
• Performs data entry of referral authorization request for primary care visits, specialty consults, diagnostic/outpatient procedures and admissions approved by the Medical Director. 
• Tracks and monitors progress of referral request, responding to request for additional information to assist the clinical staff in making a decision. 
• Reviews all incoming referral request for completeness of information provided and attempts to obtain missing information following the UM guidelines. 
• Obtains and/or clarifies CPT procedure codes, ICD-10 diagnosis codes from referring providers to assist with determination of approval/denial. 
• Ensures that network providers are utilized. 
• Handles incoming calls from physicians, ancillary providers, and patients regarding referral authorization request. 
• Review file for completeness of required documentation, including but not limited to, confirmation of receipt of notification, copies of written notification, correspondence with members and providers. 
• Monitors and facilitates reauthorization request for home health, DME and other services according to benefit guidelines. 
• Indicates out of network status to nurses when creating cases. 
• Generates all required letters and notifications to patients and providers regarding referral authorizations, medical approval, and medical denial within established timeframes, in accordance to policies, procedures, and contractual requirements. 
• Be a resource to providers and ConcertoHealth staff regarding specific denials and/or denial process. 
• Provide requested information during appeals process to support Health Plan Appeals and Grievance teams. 
• Assist other departments in creating denial documentation as requested. 
• Ensures all required data elements are present in denial correspondence. 
• Use Concerto SSRS reports to ensure all steps of process have been followed for referrals/authorizations. 
• Complete other duties and special projects as assigned. 


QUALIFICATIONS 
• High School diploma or GED. 
• Minimum two (2) years’ experience in managed care or health care setting. 
• Knowledge of Medical Terminology and/or Certified Medical Assistant preferred. 
• Typing 45wpm. 
• Ability to navigate multiple PC applications simultaneously. Knowledge and experience using Microsoft ® Office required. 
• Possess an understanding of Managed Care including referral requirements. 
• Excellent written/verbal communication skills. 
• The ability to communicate telephonically in a professional and effective manner in a fast-paced environment. 
• Strong attention to detail. 
• Display patience and demonstrates respect for callers and staff. Maintains composure in high pressure situations. 
• Strong organizational and time management skills. Able to work independently, but also as a team player 
• Ability to convey a positive and professional image to customers and employees. 
• Willingness to embrace and promote change as required by the needs of the business.