UM Coordinator - Denials

Astrana Health, Inc.; Monterey Park (CA); Hybrid; USD 29,000 - 36,000; Full time

Benefits offered by this job

Hybrid work arrangement

Overtime opportunity

Job summary

Astrana Health, Inc. is seeking a dedicated Utilization Management (UM) Coordinator – Denials in Monterey Park, CA. This role processes prior authorization denials in line with NCQA and health plan requirements while maintaining HIPAA privacy and high accuracy standards.

The position offers a hybrid in-office/remote schedule with potential overtime based on daily volume. Requires strong knowledge of UM processes and regulatory guidelines.

Qualifications

• High school diploma or GED required.
• Knowledge of ICD-10, CPT, HCPCS, and RVS codes.
• Proficient in Microsoft Office and UM software (InterQual, MCG).
• Strong organizational, decision-making, and problem-solving skills.
• Excellent verbal and written communication.
• Typing speed of at least 40 wpm.

Responsibilities

• Adhere to policies and regulations (Health Plan, DMHC, DHCS, CMS, NCQA).
• Process deferrals and denials with documentation.
• Review eligibility and benefits verification.
• Communicate with providers and departments to ensure service quality.
• Process daily deferrals/denials per guidelines and timelines.
• Verify member eligibility and benefits for deferrals/denials.
• Maintain UM/Denial system data and turnaround times.
• Apply denial templates per LOB and guidelines.
• Ensure correct criteria and reading level for denials.
• Ensure denial packets are complete with required docs.
• Assist with Failed Fax Reports and Inquiries.
• Report activities to UM Denial Supervisor/Manager.
• Maintain HIPAA privacy and data integrity.
• Collaborate on quality improvement initiatives.

Skills

Medical terminology

ICD-10/CPT codes

UM software InterQual MC G

Microsoft Office

Typing 40 wpm

Communication skills

Organizational skills

Education

High school diploma or GED

Tools

InterQual

MCG

Microsoft Office

Job description

UM Coordinator - Denials

Department: HS - UM

Employment Type: Full Time

Location: 1600 Corporate Center Dr., Monterey Park, CA 91754

Reporting To: Felicia Calles

Compensation: $21.00 - $26.00 / hour

Description

Astrana Health is seeking a dedicated Utilization Management (UM) Coordinator – Denials to join our Denial Department. This role ensures timely and accurate processing of all deferrals and denials in compliance with Astrana Health policies, NCQA standards, health plan requirements, and federal and state regulations. The UM Coordinator – Denials will review, monitor, and process prior authorization denials requests while maintaining strict adherence to regulatory and health plan guidelines.

We are seeking candidates who are flexible and interested in working additional hours, including overtime. Overtime need is determined each day based on volume.

Our Values:

• Put Patients First
• Empower Entrepreneurial Provider and Care Teams
• Operate with Integrity & Excellence
• Be Innovative
• Work As One Team

What You'll Do

• Adhere to Astrana Health policies and all applicable regulations, including Health Plan, DMHC, DHCS, CMS, and NCQA standards.
• Process and attach deferrals, denials, and associated documentation accurately.
• Review eligibility and benefits verification.
• Manage provider and interdepartmental communications, delivering excellent customer service.
• Accurately review and process daily deferrals and denials in accordance with IPA and health plan turnaround guidelines.
• Review and process assigned deferrals or denials (e.g., denial, modify, carve-out) in compliance with policies, accreditation, and regulatory standards.
• Verify member eligibility, benefits, and deferral/denial requirements.
• Maintain accurate UM/Denial system data and meet turnaround time standards.
• Apply appropriate denial templates based on Health Plan, Line of Business (LOB), and threshold language.
• Ensure correct criteria are used according to hierarchy and LOB, utilizing only approved standards.
• Verify that denial verbiage is written at the appropriate reading ease and grade level based on LOB.
• Ensure denial packets are complete before finalization, including denial letter, authorization request, proof of receipt, clinical guidelines, and medical records.
• Assist with Failed Fax Reports, Denial Inquiries, and Appeal/Grievance Inquiries.
• Report activities or issues to the UM Denial Supervisor/Manager throughout the day
• Maintain a high level of integrity and confidentiality, ensuring compliance with HIPAA standards.
• Collaborate with UM department and participate in quality improvement initiatives.
• Perform other duties as required to support the department.

Qualifications

• High school diploma or GED required.
• Knowledge of medical terminology, ICD-10, CPT, HCPCS, and RVS codes.
• Proficient in Microsoft Office and UM software (e.g., InterQual, MCG).
• Strong organizational, decision-making, and problem-solving skills.
• Excellent verbal and written communication.
• Able to work effectively in a fast-paced, team environment.
• Minimum typing speed of 40 wpm.
• Preferred:
  • At least 1 year with a Health Plan or MSO.
  • Experience with health plans, managed care organizations, or hospital UM departments
  • Familiarity with Health Plan, DMHC, DHCS, CMS, and NCQA requirements.
  • Ability to prioritize and delegate tasks effectively.

Environmental Job Requirements and Working Conditions

• This is a hybrid position. The position will be fully in-office for 3 month probationary period. After successful completion of probationary period, this position will possibly transition to 2 days in-office and 3 days at home, per employee performance. The position is located at 1600 Corporate Center Dr, Monterey Park, CA 91754.
• This position requires open availability M-Su 8 A - 8 P. Weekends and holidays are rotated amongst the team, and there is mandatory overtime in this position.
• The national target pay range for this role is $21.00 - $26.00 per hour. Actual compensation will be based on geographic location (current or future), experience, and other job-related factors.

Astrana Health is proud to be an Equal Employment Opportunity and Aff... We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at [e-mail] to request an accommodation.

Additional Information:

The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.