UTILIZATION MANAGEMENT COORDINATOR II MSO

Essential Job Functions

• Review Referral Requests and Treatment Authorization Requests received daily; process and approve authorization requests according to the NEMS MSO Authorization Grid and established clinical guidelines.
• Provide guidance to junior UM Coordinators during research of additional clinical guidelines from different sources for complex cases.
• Lead the junior UM Coordinators to prepare and present complex cases to Medical Director for review and ensure follow up activities.
• Review the confirmed MD approval/modification/denial decision and notes for record tracking purposes.
• Prepare UM Notice of Action (NOA) to provider and member for UM denial decision per AB1455 turn-around-time requirement.
• Prepare UM statistical reports and submit to health plans per contract requirement.
• Perform Care Coordination activities with members, families, specialists, and ancillary providers for authorized services.
• Perform case investigation for member and/or provider complaints and appeals related to UM denials, and report findings to Health Plan.
• Provide transition of care services to members who are discharged from the hospital.
• Perform customer services for UM inquires to PCP, specialist, and members.
• Stay current with DHCS regulations, Health Plan agreements, and Industry Standard guidelines applicable to healthcare programs.
• Communicate with Health Plan for clarification about clinical guidelines for covered/uncovered benefits.
• Communicate UM related information and updates to all members of the health care team, patients, and their families.
• Follows the appropriate turnaround timeframe for decisions and notification of members and providers.

Qualifications

• BS/BA Degree in Health Science or General Education highly preferred.
• Minimum of one year of experience in utilization management required.
• Recent experience in a clinic or outpatient setting desirable; able to perform efficiently and appropriately in a busy environment.
• Current Medical Assistant Certification or California Pharmacy Technician License or equivalent experience in a health care field is a plus.
• Knowledge of medical terminology is a must.
• Strong communication, analytical, and problem-solving skills.
• Knowledge of community resources and cultural needs.
• Good organization and prioritization skills, outstanding in time management.
• Must be able to fluently speak, read and write English.
• Freshman level proficiency in Chinese (Cantonese and/or Mandarin) preferred.
• Freshman level proficiency in other languages is an asset.