Utilization Management Coordinator

Responsibilities

• Receives requests for prior authorization, concurrent review, post service, or a claim review, and enters the request in the Utilization Management Platform.
• Checks eligibility, network status, procedure coverage, prior authorization status, and obtains clinical records in order to prepare authorization for RN or MD review.
• Communicates the authorization determination to the requestor and/or member.
• Answers and/or responds to calls from operational phone queues.
• Affords assistance to providers and members by confirming benefits, verifying member eligibility, quoting prior authorization status, and answering questions about prior authorizations.
• Safeguards Utilization Management processes with Medical Review Officers, UM Nurses, hospitals, physicians, and other various internal and external customers.
• Maintain understanding of business rules and regulatory requirements pertaining to UM processes and operations.
• Other duties as assigned for preservice, concurrent review, post service and claim reviews.

Requirements

• Demonstrated potential ability to perform the essential functions as outlined above.
• Demonstrated human relations and effective communication skills.
• Demonstrated computer literacy.
• Ability to handle highly sensitive and confidential issues in a professional manner.
• Ability to prioritize and organize tasks.

Qualifications

• Two years of health care experience or education equivalency.
• Understanding of medical terminology.
• Previous experience in a utilization review setting (preferred).