SBS - Utilization Authorization Coordinator (UM Review Nurse)

Santa Barbara Select is an Independent Physician Association (IPA) that functions under Desert Physicians Management (DPM). DPM is a physician-owned managed care network with 200+ physicians and multiple urgent care facilities.

Some administrative responsibilities include:

• Managed care operations
• Claims adjudication
• Utilization management
• Provider network administration

We are seeking a dedicated and detail-oriented Utilization Authorization Coordinator (UM Review Nurse) to join our team. This vital role involves reviewing medical documentation, authorizing appropriate patient care services, and ensuring compliance with healthcare regulations. The ideal candidate will possess strong clinical knowledge, experience with managed care processes, and proficiency in electronic health record systems to facilitate effective utilization management and optimize patient outcomes.

• Participate in the authorization review process, including pre-service and retrospective requests (including retrospective claims) and audit process with each health plan.
• Regularly maintain and report on DME Utilization, Home Health Utilization, Pharmacy Utilization, UM Utilization and turn-around times, and member services assistance on UM issues
• Ensure timely and accurate processing of all authorizations and verify referral completion per regulations, policies, and procedures
• Coordinating with healthcare providers and/or specialists, utilization management team, and compliance departments to ensure appropriate utilization of healthcare services
• Communicate directly with providers and specialists regarding documentation, obtaining additional information from practitioners' offices, as needed
• Provide ongoing support and training for staff on documentation requirements, and medical necessity updates
• Conduct initial review of medical information and identify initial determination of benefit coverage
• Preparing and providing clinical justification to insurance companies to reduce denials
• Review approval of medically routine referrals and preliminary denial for eligibility
• Participate in the development and implementation of the referral functions
• Monitor workflow queues to ensure timely processing of all referrals
• Collaborate and defer to Medical Director for escalated cases
• Monitor home health reports and NOMNCS
• Review patient notes for medical necessity
• Communicate approvals to clinics or providers
• Participate in Joint Operational Committees (JOC)
• Participate in health plan audits
• Other duties as assigned
• Must possess an active, unrestricted Licensed Vocational Nurse (LVN) license and/or a Registered Nurse (RN) license, issued by the State of California's Board of Nursing.
• Minimum of two (2) - four (4) years' experience in the healthcare management managed care environment required and experience in managing, analyzing, and reporting denials and appeals.

This is a great opportunity to become a part of a growing organization that is dedicated to improving healthcare experience. Apply today and join us in our mission to deliver superior services, ensuring health and quality of life to the people in the communities we serve! Equal Employment Opportunity (EEO)/Americans with Disabilities Act (ADA): We are an Equal Employment Opportunity (EEO) and Americans with Disabilities Act (ADA) compliant employer, committed to providing equal employment opportunity to all employees and applicants.

Pay:

$48.00 - $55.00 per hour Expected hours: 40.0 per week

Benefits:

401(k) Dental insurance Health insurance Life insurance Paid time off Vision insurance

Work Location:

In person