UM Coordinator I

Community Health Center Network; San Leandro (CA); On-site; USD 32,000 - 45,000; Full time

Job summary

The Community Health Center Network (CHCN) seeks a UM Coordinator I to provide administrative support, handle prior authorizations, and serve as a resource for members, providers and staff. The role emphasizes accuracy, confidentiality, and timely processing in a health care environment.

Ideal candidates bring strong communication skills, attention to detail, and familiarity with CPT/HCPCS, ICD-10, and state/federal insurance programs, in a regular full-time on-site setting in California.

Qualifications

• Detail-oriented with problem-solving abilities.
• Excellent written and verbal communication skills.
• Proficient in CPT/HCPCS and ICD-10 codes.
• Ability to handle detailed work and maintain confidentiality.
• Minimum 1–2 years health care experience with medical records, medical billing, or medical office.
• Experience with State and Federal insurance programs.
• Current Medical Assistant Certification or California Pharmacy Technician License or equivalent health care experience.
• High school diploma or GED.

Responsibilities

• Research medical utilization management requests using various resources.
• Refer cases to UM Nurses, Case Managers, including the Medical Director for clinical review.
• Provide administrative and clerical support for utilization management and case management activities.
• Answer questions and resolves issues from members and providers about referrals, verification, eligibility, and authorizations.
• Ensure PHI privacy and security in line with HIPAA policies.
• Make calls to members and providers per UM/CM protocols.
• Communicate with health plan UM staff, providers, inpatient staff, and government entities.
• Enter prior authorization data into EZ-CAP or other databases accurately.
• Meet turnaround time requirements for authorizations and letters.
• Draft denial letters per UM Nurses/Medical Director decisions.
• Coordinate activities with UM & CM staff and CHCN.
• Attend required meetings and respond to Customer Care inquiries.
• Coordinate with CHCN Provider Relations on LOA updates and contract negotiations.
• Support claims with verification of authorization status.
• Provide provider education to CHCN staff and escalation to UM Supervisor when needed.
• Maintain regular attendance and knowledge of CHCN lines of business.
• Adhere to compliance requirements regarding turnaround times.

Skills

Communication skills

Detail oriented

Problem solving

Education

High School Diploma or GED

Medical Assistant Certification or Pharmacy Technician License

Job description

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

2 days ago Requisition ID: 1096

Organizational Description

The Community Health Center Network (CHCN), sister organization to the Alameda Health Consortium, is made up of the eight federally qualified community health centers in Alameda County. CHCN functions as the managed care MSO for our health centers, contracting with the Alameda Alliance for Health. In order to help our health centers meet their missions of providing the best possible care to their communities, we also provide a broad range of training, technical assistance, quality improvement, information technology, and data analytic services.

Department: Care Management (UM)

Reports To: UM Coordinator Supervisor

Classification: Non-Exempt

Status: Regular Full-Time

Salary Range: $27.89 hourly

POSITION SUMMARY

The UM Coordinator I is responsible for serving primarily in an administrative support capacity and providing exceptional health care support services to the CHCN members, providers, and staff. The duties of this position include making telephone calls to members and providers serving as resource agent to internal and external customers, as well as, processing prior authorization requests within compliance guidelines.

ESSENTIAL POSITION RESULTS

The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks and responsibilities. Employees may perform other duties as assigned.

• Research medical utilization management requests using a variety of resources including the Health Plans’ evidence of coverage, CHCN policies and procedures, industry healthcare resources and State eligibility verification systems..
• Refer cases to UM Nurses, Case Managers, including the Medical Director, for clinical review, potential denial or modification.
• Provide administrative and clerical support for utilization management and case management activities.
• Answer questions and resolves issues promptly from members and providers pertaining to referrals, benefit verification, eligibility verifications function and authorization status and modification request.
• Ensure the privacy and security of PHI (Protected Health Information) as outlined in CHCN and the Health Plans’ policies and procedures relating to HIPAA compliance.
• Make telephone calls to members and providers according to Health Plans/CHCN’s utilization management and case management protocols.
• Communicate regularly via phone with health plan UM staff, providers, inpatient staff, and select government entities such as California Children’s Services.
• Enter prior authorization required data in EZ-CAP or a selected database program with accuracy in a timely manner.
• Adhere to Health Plans/CHCN’s standards, policies, and regulations to meet Turn-Around-Time requirements for creating authorizations and delivering of denial/approval letters.
• Compose denial letters in accordance to UM Nurses/Medical Director’s decisions.
• Coordinate activities with the other staff members of the UM & CM Department and the CHCN as a whole.
• Attend and participate in required meetings.
• Respond and coordinate inquiries from Customer Care to assist with provider authorization related questions.
• Facilitate with CHCN Provider Relations departments on ancillary updates to OON providers and contract negotiation efforts through the LOA process.
• Supports claims with verification of authorization status affecting pended and aging claims review
• Provides provider education to CHCN clinic staff, ancillary providers and hospital facility in a professional and timely manner. Reports any escalation of issues to UM Supervisor for review.
• Regular and reliable attendance is an essential function of the UM Coordinator I position.
• Maintain current and detailed knowledge of lines of business managed by CHCN
• Consistently adhere to compliance requirement regarding Turn- around Time mandates.

SUPERVISORY RESPONSIBILITIES

None

MINIMUM QUALIFICATIONS

• Must foster a “Can-Do” attitude
• Detail-oriented with problem-solving abilities
• Excellent written and verbal communication skills, to allow for effective communication at all levels
• Proficient in CPT/HCPCS and ICD-10 codes.
• Organized and self-managed person with the desire to learn and the ability to work well with others.
• Knowledge and application of English grammar including composition, editing and proofreading skills.
• Strong organization, time management and multi-tasking abilities.
• Ability to handle detailed work, work with varying types of data and maintain confidentiality.
• Ability to display a courteous, patient, and helpful attitude toward co-workers at CHCN organization.
• Basic understanding of Health Plans/CHCN’s policies and procedures.
• Minimum of one to two years previous health care experience with medical records, medical billing, or medical office experience.
• Minimum of one year of experience with State and Federal insurance programs
• Current Medical Assistant Certification or California Pharmacy Technician License or equivalent experience in a health care field with familiarity with medical terminology and concepts, required.
• Experience in an HMO/IPA or experience in a managed care setting a plus.
• High school diploma or General Education Degree (GED) required

General CHCN roles:

• Foster an environment that promotes trust and cooperation among clients and staff.
• Enforce policies and procedures, including maintenance of client confidentiality, to ensure that the principles of CHCN are implemented.
• Be accountable for participating in decision making processes and understanding the outcome(s).
• Understand the values and principles of CHCN and applies them in work responsibilities.
• Participate in outreach activities, agency advocacy, and serves on ad hoc committees, as requested.
• Attend and participate all required CHCN meetings.

CERTIFICATES AND/OR LICENSES

None

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit and use hands to finger, handle, or feel. The employee is frequently required to talk or hear. The employee is frequently required to stand; walk; reach with hands and arms and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus.

WORKING CONDITIONS AND ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly exposed to an insideenvironment.

The Community Health Center Network is an Equal Opportunity Employer.