Clinical Services UM Coordinator

Clinical Services UM Coordinator

PHYSICIANS DATA TRUST

Vista, CA Job Details Full-time $18 - $27 an hour 5 hours ago Qualifications Computer operation Phone communication English High school diploma or

GED ICD-10 CPT

coding Medical terminology

Full Job Description Primary Purpose:

Data input of referral authorization requests received from the Organization's Contracted Providers; generate member notifications as directed. Principal Duties and Responsibilities (

• = essential functions): Verifies eligibility and benefits for each referral.
• Performs data entry of referral authorization requests for primary care visits, specialty consults, diagnostic/outpatient procedures, and admissions approved by the Medical Director.
• Tracks and monitors progress of referral requests, responding to requests for additional information to assist the medical director's staff in making a decision.
• Primary telephone call process for incoming calls into the Utilization Management Department.
• Provides referral and authorization notifications to providers as directed.
• Organizes and maintains electronic and hard copy filing systems for authorizations/referrals as directed.

Prepares assigned correspondence and reports and complies with statistical data as directed. Tracks all types of references on the computer system on a hard copy log and compiles statistics monthly. Supports and facilitates teamwork within the department/group and the organization. Obtains CPT procedure codes and ICD-10 diagnosis codes from referring providers to assist with the determination of approval/denial. Ensures that network providers are utilized. Handles incoming calls from physicians, ancillary providers, and patients regarding referral authorization requests. 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 requisition requests for home health DME and other services in accordance with benefit guidelines. Coordinates all out-of-network outpatient specialist referrals 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 with policies, procedures, and contractual requirements. Provide the requested information during the appeals process. To organize and act promptly on pending denial files/cases to maintain designated turnaround times and physician communication. To provide information to licensed nursing staff regarding referrals that are 'not a covered benefit' and facilitate denial letters. To organize, manage, and prioritize workload effectively to process authorization request forms within the established time frame.

• To refer appropriate authorization request forms to the IPA case manager based on established criteria.

To educate and inform physicians and their office staff of any changes to the referral process, network changes, or other information about the referral process. Assist other departments in creating denial documentation during the appeals process. 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. Ensure all required work is completed on time by the end of each shift. Participates in scheduled departmental/group meetings. Represents the department/group and organization professionally and positively. To perform other duties as assigned. Job Specifications (KSAs): Six months of experience in the medical field, either in a hospital, clinical, or insurance setting, that includes experience with computers. The ability to read, write, and speak English and perform other basic educational skills, as is generally obtained by completing High school or a GED equivalent. Bilingual English/Spanish preferred. Clear and accurate knowledge of medical terminology; managed care experience and knowledge preferred. Working knowledge & expertise of

ICD-10 & CPT-4

codes. Demonstrated computer literacy. Excel experience helpful. Excellent communication skills in both oral and written modes, as well as superior telephone etiquette. Excellent Customer Service experience and proficiency required. Pay Range $18 - $27.00 hourly DOE.