Referral Coordinator Managed Care

Universal Healthcare MSO, LLC; Bakersfield (CA); On-site; USD 29,000 - 36,000; Full time

Benefits offered by this job

Dental

Floating Holiday

Employer Paid Life Insurance

Employee Assistance Program

Job summary

Universal Healthcare MSO, LLC is seeking a UM Referral Coordinator Level I to support the clinical team in processing prior authorizations and verifying patient eligibility. The role requires strong clerical skills, attention to detail, and effective communication with providers and plans.

The position is in an office setting in California, with responsibilities including coordination of care, handling denials, and adherence to health plan guidelines.

Qualifications

• High school diploma or equivalent required.
• 1-2 years healthcare admin experience preferred.
• Experience with medical billing/authorizations preferred.

Responsibilities

• Process medical authorizations per policies/procedures.
• Verify eligibility, benefits and contract status for providers.
• Coordinate with UM staff, medical directors, and plans.
• Assist with authorizations for DME, home health, IV antibiotics, transfers.
• Assist with CMS notices and quality improvement initiatives.

Skills

CPT/ICD codes

Medical terminology

Contract language

Customer service

Data entry

Office equipment

Education

High school diploma

Medical billing/coding training

Tools

Microsoft Office

Job description

Classification: Full-Time This position is non-exempt and will be paid on an hourly basis. Universal Healthcare MSO's standard operating hours are Monday through Friday, from 8:00 a.m. To support business operations and after-hours member needs, employees within the Utilization Management (UM) department may be assigned schedules that differ from standard business hours. Medical

• Dental
• Floating Holiday
• Employer Paid Life Insurance
• Employee Assistance Program

Compensation: The initial pay range for this position upon commencement of employment is projected to fall between $20.96 and $26.19. Reporting to the Utilization Management leadership, the Referral UM Coordinator Leve I plays a pivotal role in furnishing essential clerical support and aiding the clinical team within the UM department on a day-to-day basis. This pivotal position assumes responsibility for efficiently handling a substantial volume of prior authorization requests. The UM Referral Coordinator Level I ensures that all orders and referrals align with the health plan's benefits and promptly escalates any exceptions to the UM clinical team. In adherence to UM guidelines and carve-out processes, certain authorizations are approved at a UM Coordinator level by the UM Referral Coordinator. This role also encompasses the critical task of validating eligibility, benefits, and contract status for requested providers. On a regular basis, the UM Referral Coordinator Level I interacts with various stakeholders, including UM staff, Medical Directors, other healthcare providers, health plans, and relevant personnel both within and outside the organization. The UM Referral Coordinator Level I diligently and accurately processes medical authorizations, strictly adhering to company and departmental policies and procedures. Furthermore, this position assumes the responsibility of independently managing assigned tasks and activities, following established policies and procedures with precision and expertise. Accurately processes medical authorizations according to company/department policies and procedures.

• General knowledge of CPT and ICD9/ICD10 and HCPCS codes relates to the processing of medical billing and/or authorizations.
• Familiar with medical terminology as it relates to IPA's, PPO's and HMO's
• Ability to interpret and communicate complex contract or benefit language.
• Ability to identify issues and problems within administrative processes and other relevant areas.
• Conducts calls to providers, facilities, vendors for additional information on authorization requests, as needed.
• Troubleshoot calls from members, providers, health plans, hospitals, and other business affiliates to facilitate a seamless UM service.
• Handles UM Department's mailing distribution and assisting in mail room, which may require scanning and inputting data in accordance with department practice.
• Implements patient discharge plans delegated by Inpatient UM Nurse by coordinating with home care agencies, post-acute care facilities, durable medical equipment companies, transportation agencies and others as indicated.
• Ability to communicate effectively with all levels of internal/external staff, management, members, physicians/physician office staff.
• Knowledge of generally accepted professional office procedures and processes.
• Ability to use the following general office equipment correctly and safely: desktop

computer for data entry and typing, copy machine, scanner, facsimile machine, and telephone equipment.

• Ability to create professional documents using proper grammar and punctuation.
• Ability to handle various situations in a professional manner, always demonstrating excellent customer service and ability to adapt to change.
• Coordinates continuity of care with external healthcare organizations and facilities, including the process of obtaining authorizations for services as directed by the clinical staff.
• Assist with creating and faxing authorizations for DME, HH, IV antibiotics, facility transfers, and other health care needs.
• Participates in Patient-Centered quality improvement initiatives.
• Assist in mailing, sending, and gathering CMS notices from home health agencies and skilled nursing facilities.
• Process Denial Letters while adhering to health plan requirements, CMS, and DHCS.
• Updating and maintaining the most current required Health Plan templates
• High school diploma or equivalent required.
• 1-2 years working in a health care or other related business environment working in authorizations, medical assisting and/or medical billing services preferred.

• General knowledge of Microsoft Office applications; Excel, Word; Completion of vocational school program in medical assisting, medical front office, or medical billing and coding preferred.

• Ability to create professional documents using proper grammar and punctuation.
• excellent customer service and ability to adapt to change.
• Ability to continually re-prioritize to meet the needs of internal and external customers throughout the workday.

• Ability to adhere to dress code, good grooming, and personal hygiene habits.
• Ability to maintain knowledge of and conform to company policies and procedures.
• Standard office setting with regular use of computers and other office equipment.
• Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions of this position.

This position is primarily performed in a professional office environment and requires the ability to:

• Frequently remain seated and stand throughout the workday while performing assigned duties.
• Occasionally lift materials weighing up to 15 pounds from floor to waist level and up to 10 pounds at waist level and above.
• Occasionally carry, push, pull, and transport work-related materials or equipment.
• Frequently use a computer, keyboard, mouse, telephone, and other equipment requiring repetitive hand and wrist movements.
• Work in environments where exposure to bloodborne pathogens, chemicals, airborne communicable diseases, extreme temperatures, uneven surfaces or elevations, extreme noise levels, and dust or particulate matter may be reasonably anticipated.