Utilization Management Coordinator

Independent Living Systems, llc; Miami (FL); On-site; USD 42,000 - 54,000; Full time

Job summary

Independent Living Systems, llc in Miami, FL is seeking a full-time Utilization Management Coordinator. This role reviews prior authorization forms for completeness, determines if services require authorization, and communicates with internal and external customers to facilitate timely access to care.

The position emphasizes adherence to healthcare regulations, medical terminology, and collaboration with Clinical Care Specialists to ensure efficient processing of requests and improved member

Qualifications

• High school diploma or equivalent required.
• 2 years of medical office referral/authorization experience.
• Strong knowledge of healthcare regulations and medical terminology.
• Relevant experience may substitute for the educational requirement on a year-for-year basis.

Responsibilities

• Review prior authorization requests for documentation completeness.
• Determine if the requested service requires authorization.
• Place outbound calls to obtain clinical information as needed.
• Screens and routes requests to the Clinical Care Specialist as appropriate.
• Support timely processing to improve member outcomes.

Skills

Medical office experience

Healthcare regulations knowledge

HIPAA knowledge

CMS guidelines familiarity

Florida Medicaid familiarity

Medical terminology proficiency

Education

High school diploma or equivalent

Associate degree in Health Administration or related field

Job description

Full Time Clerical Miami, FL, US

About the Role:

The Utilization Management Coordinator plays an essential role in ensuring that the authorization requests are processed effectively. The Utilization Management Coordinator reviews the prior authorization form received for documentation completeness and determines if the requested service requires an authorization. This role includes inbound and outbound communication with both internal and external customers. Ultimately, the Utilization Management Coordinator contributes to improving member outcomes by facilitating timely access to necessary care.

Minimum Qualifications:

• High school diploma or equivalent required
• 2 years of experience as a medical office referral/authorization clerk, office assistant or other medical office experience.
• Strong knowledge of healthcare regulations, and medical terminology.
• Relevant experience may substitute for the educational requirement on a year-for-year basis.

Preferred Qualifications:

• Associate degree in Health Administration, or a related healthcare field
• Certification in Utilization Review (e.g., Certified Professional in Utilization Review - CPUR) or Case Management (e.g., CCM).
• Experience working within managed care organizations or health insurance companies.
• Familiarity with regulatory requirements such as Florida Medicaid/SMMC and CMS guidelines, HIPAA and current health plan accreditation standards,.

Responsibilities:

• Demonstrate commitment to Our Mission and models ILS Experience Standards of Excellence.
• Continuously reviews prior authorization requests received via oral, provider portal, fax and/or email to ensure timely processing.
• Screens prior authorization requests for appropriate referral to the Clinical Care Specialist.
• Performs non-medical research including eligibility verification, reviewing the prior authorization grid to confirm if services do or do not require prior authorization.
• Places outbound calls to providers to request clinical information for review.