Utilization Management Coordinator

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The UM Coordinator is responsible for processing phone, email, and fax authorization requests for vision medical-surgical services in an efficient, accurate, and compliant manner.

Organizational Relationships

Reports To:

Manager, UM and Director of Network Development

Clients: 

Physicians, Office Administrators, Members, Health Plans

 Works With: 

All levels of iCare Health Solutions Staff

Essential Duties and Responsibilities

A.   Primary

  1. Effectively handles vision medical-surgical authorization requests and inquiry phone calls from providers, Support Services, and Health Plans in compliant and efficient manner.
  2. Based on the information received from the provider and gathered from computer systems, determines the appropriate handling of each authorization request.
  3. Timely enters authorization requests into systems after review with minimal errors and contacts office when additional information is required in order to process.
  4. Follows appropriate procedure for verifying member eligibility, authorization history, and network participation status.
  5. Works with moderate to minimal assistance in processing authorization requests and pro-actively seeks answers to questions.
  6. Assist in mentoring and training new hire UM Coordinators for success.
  7. Prioritizes authorization requests by level urgency STAT, Expedited, or Standard
  8. Establishes and maintains relationships with our providers, contracted Health Plans, and the staff to facilitate processing authorizations requests within compliance and efficiency.
  9. Effectively communicate with provider’s authorization status and details with excellent customer service skills.
  10. Fax, email, or mail authorization letter to provider’s office and member.
  11. Prepare denial recommendations to Health Plans by attaching the clinical information received, iCare criteria, denial recommendation letter, and medical director notes for UM Managers review.
  12. Negotiate and enter Letter of Agreement with special fees for non-par physicians when circumstances arise for urgent care or with coverage area limitations.
  13. Notifies’ provider offices via fax and/or phone that need to contact the member’s assigned ophthalmology provider to obtain authorization.
  14. Based on authorization rules and urgency, either approves the authorization request, sends to manager or Medical Director for review.
  15. Assist in preparing and submitting UM Department projects, reports or assignments as needed to meet department initiatives, Health Plan reporting, and/or objectives.
  16. Review Daily Pend Log and authorization requests in order to prioritize work-load efficiently.
  17. Escalate provider complaints/calls as needed to UM Manager, Director, or Provider Relations to maintain providers, member and health plan satisfaction.
  18. Notifies UM Manager or Director of any re-occurring UM issues or opportunities for process improvement.

Minimum Qualifications

Education

Must have high school diploma or general education degree (GED).

Experience & Job Knowledge

Minimum of 1 year related customer service, administrative, or call center in managed care or optical setting. Knowledge of medical terminology and coding including optical preferred.

Skills

Ability to read, assess, and process authorization requests timely. Excellent communication skills including good grammar, voice and diction. Ability to navigate software systems and proficient in MS Office with basic computer and keyboarding skills. Excellent customer service skills. Proactive in conflict resolution.

Required Abilities

Physical

Requires corrected vision and normal hearing range, requires sitting for extended periods and extended periods of computer use; may also require standing, walking, bending, kneeling, and crouching; occasionally lifts and carries items in excess of 5 to 10 lbs. but not more than 20 lbs. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

Core Competencies

Commitment and Accountability: must produce promised results in a timely manner.  Must coordinate and manage multiple authorization requests and provider calls.

Professionalism:  must work professionally with all levels of internal and external customers to other departments, associates and clients.

Communication: must communicate verbally and in written form in a professional, logical, and persuasive manner with external and internal clients.

Motivation and Initiative: must have the initiative and ability to work independently and in an unsupervised environment.

Judgment: must analyze problems, develop courses of action, and implement decisions that are consistent with department policies, procedures and/or objectives.

Planning: must effectively organize, prioritize, and carry out numerous tasks simultaneously.  Must adjust to changes quickly and in a positive manner.

Working Conditions

Work is performed indoors in a controlled environment.  Occasional reports and meetings require attendance after regular business hours.

 

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2018-02-07T22:32:58+00:00