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TEMP UM Coordinator at ConcertoHealth
Aliso Viejo, CA, US

 

JOB SUMMARY

The UM Coordinator 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 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.
  • Obtains 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.
  • Coordinates all out of network outpatient referrals to specialist with the Medical Director.
  • 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.
  • Assist other departments in creating denial documentation as requested.
  • Document denial and denial rationale in data management systems.
  • Maintains/updates all required reporting for referrals/authorizations. 
  • Complete other duties and special projects as assigned.
  • Ensures that all required work is completed timely by the end of each shift

  

QUALIFICATIONS

  • High School diploma or GED.
  • Minimum two (2) years’ experience in managed care or health care setting.
  • Knowledge of Medical Terminology.
  • 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.