UM Coordinator

Advanced Medical Management, Inc.; Long Beach (CA); On-site; USD 40,000 - 60,000; Full time

Benefits offered by this job

Full employer-paid HMO

Discounted vision and dental premiums

401(k) plan

Generous PTO

Tuition reimbursement

Paid company outings and lunches

Job summary

Advanced Medical Management, Inc. in Long Beach, California, is seeking a Utilization Management Coordinator to coordinate prior authorization requests and support utilization review activities. The candidate will work closely with health plans, providers, and internal departments to ensure compliance with CMS and DHCS regulations.

Required qualifications include a High School Diploma and at least one year of healthcare experience. The position offers a range of benefits including health coverage, paid time off, and professional development opportunities.

Qualifications

• Knowledge of medical terminology, ICD-10 diagnosis coding, and CPT/HCPCS procedure coding.
• Experience in healthcare with managed care experience preferred.
• Familiarity with HIPAA regulations and CMS regulations.

Responsibilities

• Coordinate prior authorization requests and processing referrals.
• Document case activity and support timely utilization review activities.
• Ensure compliance with CMS, DHCS, and NCQA requirements.

Skills

Strong organizational skills

Time management

Critical thinking

Multitasking

Problem solving

Ability to prioritize urgent work

Education

High School Diploma or GED

Tools

EZCAP Authorization System

Microsoft Outlook

Microsoft Word

Microsoft Excel

Adobe Acrobat

Electronic Fax Systems

Electronic Health Records (EHR)

Job description

The Utilization Management (UM) Coordinator is responsible for coordinating prior authorization requests, processing referrals, documenting case activity, and supporting timely utilization review activities using the EZCAP Authorization System. The coordinator ensures compliance with CMS, DHCS, NCQA, and contracted health plan requirements while maintaining excellent customer service to providers, members, and internal departments.

The UM Coordinator serves as the first point of contact for authorization requests and works closely with nurses, medical directors, case managers, provider offices, and health plans to ensure timely and accurate processing of requests.

Essential Duties and Responsibilities

Authorization Management

• Receive and process prior authorization requests through EZCAP.
• Verify member eligibility and health plan benefits.
• Verify provider participation and network status.
• Determine whether requests qualify for auto-approval.
• Create new authorization records in EZCAP.
• Enter accurate clinical and demographic information.
• Assign requests to the appropriate review queue.
• Prioritize urgent and expedited requests according to CMS requirements.
• Maintain authorization documentation throughout the review process.
• Process duplicate and corrected authorization requests.

EZCAP Responsibilities

• Create and update authorization cases.
• Document all provider communications.
• Upload supporting medical records.
• Scan and attach incoming documentation.
• Update authorization status throughout the review process.
• Route cases to UM Nurses and Medical Directors.
• Verify authorization history.

Provider Communication

• Receive incoming provider telephone calls.
• Respond to fax and portal authorization requests.
• Obtain missing clinical documentation.
• Notify providers of additional information requests.
• Escalate clinical questions to UM Nurses.
• Coordinate with provider offices regarding duplicate requests.

Documentation

Accurately document:

• Date and time of request
• Source of request
• Clinical information received
• Communication attempts
• Fax confirmations
• Telephone conversations
• Medical record receipt
• Authorization status changes

Regulatory Compliance

Maintain compliance with:

• CMS Medicare Advantage regulations
• DHCS Managed Care requirements
• Health plan contractual requirements
• Organization UM Policies and Procedures
• HIPAA Privacy and Security requirements

Monitor authorization turnaround times including:

• Urgent requests
• Standard requests
• Additional information requests
• Extension notifications
• Pending authorizations
• Escalations approaching regulatory deadlines

Quality Responsibilities

• Follow departmental workflows.
• Meet production standards.
• Participate in internal audits.
• Attend required training sessions.
• Assist with audit preparation.

Daily Responsibilities

• Process fax requests.
• Process portal requests.
• Follow up on pending cases.
• Upload clinical documentation.
• Assist nurses with non-clinical tasks.
• Complete assigned production goals.

Required Knowledge

Knowledge of:

• Medical terminology
• ICD-10 diagnosis coding
• CPT/HCPCS procedure coding
• Managed Care operations
• HIPAA regulations
• CMS regulations
• NCQA standards

Knowledge of EZCAP preferred.

Required Skills

• Strong organizational skills
• Time management
• Critical thinking
• Multitasking
• Problem solving
• Ability to prioritize urgent work

Minimum Qualifications

Education

• High School Diploma or GED required

Experience

• Minimum 1 year in healthcare
• Managed care experience preferred
• Medical office experience preferred
• Health plan experience preferred

Computer Skills

Experience with:

• EZCAP Authorization System (preferred)
• Microsoft Outlook
• Microsoft Word
• Microsoft Excel
• Adobe Acrobat
• Electronic Fax Systems
• Electronic Health Records (EHR)

Performance Expectations

The UM Coordinator is expected to:

• Maintain a quality score of 95% or higher.
• Process authorizations within regulatory turnaround times.
• Accurately document all authorization activities.
• Follow all departmental policies and workflows.
• Maintain confidentiality of Protected Health Information (PHI).
• Demonstrate professionalism with providers, members, and coworkers.

AMM BENEFITS

When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:

• Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan.
• Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe.
• Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.
• Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work.
• Career Development: Tuition reimbursement to support your education and growth.
• Team Fun: Paid company outings and lunches because we work hard, but we also know how to have fun!