Care Coordinator - SCMG Utilization Management - Spectrum - Day - Full Time at Sharp HealthCare[...]

Hong Kong Study Skills Research Institute; San Diego (CA); On-site; USD 50,000 - 70,000; Full time

Job summary

Hong Kong Study Skills Research Institute is seeking a Care Coordinator in San Diego, California. In this role, you will prepare referral requests, manage prior authorizations, and coordinate retrospective claims review while ensuring compliance with regulatory requirements.

The ideal candidate will have at least 2 years of healthcare experience, strong knowledge of medical coding, and proficiency in Microsoft Word and Excel.

Qualifications

• 2+ years of experience in healthcare with knowledge of medical codes and data entry.
• Proficient in Microsoft Word and Excel; certification preferred.

Responsibilities

• Obtain necessary medical/clinical information for prior authorization.
• Verify member eligibility and benefit coverage.
• Coordinate retrospective claims for medical care.

Skills

Medical terminology

Health insurance knowledge

Organizational skills

Microsoft Word

Microsoft Excel

Education

Completion of a Medical Assistant Program

Tools

ACES/Optum Portal

IDX

OnBase

Right Fax

Job description

Responsibilities

The UM Care Coordinator, under the direct supervision of the Supervisor, Utilization Management Care Coordinators, prepares referral requests and conducts retrospective claims review for the services.

• Prior Authorization: obtain necessary medical/clinical information from multiple sources, accurately interpret criteria, document actions taken, refer requests to licensed staff, triage emails, and serve as liaison to the Care Management team.
• Benefit Verification: proficiently navigate health plan websites, verify member eligibility, obtain detailed benefit coverage, apply benefit guidelines, and research support in the benefit denial process using evidence of coverage and coverage criteria.
• Retrospective Review: coordinate, review, and process retrospective claims for medical care and services, complete the review within required regulatory turn‑around times, provide determinations, identify claims for review by the Medical Director, and forward claims with applicable information.
• Quality and Productivity Performance: achieve 90% or greater quarterly audit results, complete tasks accurately with minimal supervision, meet specified timeframes, and maintain the performance metric of referral volume per day.
• Professional Development: keep current knowledge of accreditation and regulatory statutes, report non‑compliance, mentor other teams, establish and meet annual goals, maintain performance records, and participate in departmental quality improvement activities.

Required Qualifications

• Successful completion of a Medical Assistant Program or equivalent.
• At least 2years of experience in healthcare with knowledge of medical codes, terminology, and data entry.
• Proficiency in Microsoft Word and Excel; certification preferred.

Preferred Qualifications

• Successful completion of a Medical Terminology course.
• Successful completion of ICD‑9 and CPT coding classes, or equivalent experience.
• Experience in a managed care environment with an HMO or delegated risk medical group/IPA setting.

Knowledge, Skills, and Abilities

• Excellent working knowledge of medical terminology, CPT, ICD, and HCPCS codes and appropriate utilization.
• Knowledge of health insurance or HMO benefits and referral management processes.
• Strong organizational skills, ability to work independently, plan, organize, manage changes, and prioritize multiple conflicting priorities.
• Proficiency with referral management applications such as ACES/Optum Portal, IDX, OnBase, Right Fax, and associated tools.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, disability, or any other protected class.