- Coordinate and input service requests for a review determination by the UM Reviewer, Medical Management Manager (UM Manager) and/or Health Solutions Medical Director.
- Drafting and issuing verbal and written pre-authorization and concurrent approvals/denial correspondences and notifying providers/enrollees needed.
- Collaborating with the UM Supervisor to resolve customer service inquiries and related issues.
- In support of care management initiatives, identify enrollees in need of case/disease management services and collaborate with case management teams so that proactive interventions can occur.
- Other administrative projects as assigned by the UM Supervisor or Manager, Medical Management.
- Education: High School diploma. Certification in Medical Assistance or similar associates degree preferred
- Previous experience in utilization management or healthcare operational or a related field is preferred.
- Medical Billing or Coding program completion preferred.
- Licenses/Certifications: Certified Professional Coder (CPC) Certification or similar certification preferred
- One (1) to two (2) years' experience in a Managed Care or Acute Care environment performing coordinating prior authorization, care coordination or other managed care functions involving data entry.
- Quality auding coordination and/or knowledge of relevant laws, rules, regulations and accreditation standards and requirements of a utilization management program.
- Experience with data analysis tools such as Microsoft Office Suite applications Excel, Power BI, or Tableau
- Medical billing/coding experience is a plus. Equal or comparable experience will be considered.
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UM Coordinator - Houston, United States - Apex Health Solutions
Description
Job Title: Coordinator, Utilization Management
Department: Medical Management
Supervisor: UM Supervisor/Manager, Medical Management
The Utilization Management Coordinator represents the company by serving as the frontline point of contact to providers and members for the utilization review (UR) of healthcare services. The UM Specialist works within prescribed guidelines and procedures; uses independent judgment requiring analysis of variable factors to solve basic problems; collaborates with management and top professionals/specialists in selection of methods, techniques, and analytical approach to drive business goals.
Accountable for complying with utilization review procedures in accordance with Texas UR Certification requirements while coordinating in and out of plan pre-service and concurrent service requests, continuity of care, and post-acute planning activities.
Essential Duties and Responsibilities include the following. Other duties may be assigned.
To perform the job successfully, an individual should demonstrate the following competencies:
Analytical - Synthesizes complex or diverse information; collects and researches data; uses intuition and experience to complement data; designs workflows and procedures.
Job Knowledge - Competent in required job skills and knowledge; exhibits ability to learn and apply new skills; keeps abreast of current developments; requires minimal supervision; displays understanding of how job relates to others; uses resources effectively.
Problem Solving - Identifies and resolves problems in a timely manner; gathers and analyzes information skillfully; develops alternative solutions; works well in group problem solving situations; uses reason even when dealing with emotional topics.
Communications - Expresses ideas and thoughts verbally; expresses ideas and thoughts in written form; exhibits good listening and comprehension; keeps others adequately informed; selects and uses appropriate communication methods.
Oral Communication - Speaks clearly and persuasively in positive or negative situations; listens and gets clarification; responds well to questions; demonstrates group presentation skills; participates in meetings.
Written Communication - Writes clearly and informatively; edits work for spelling and grammar; varies writing style to meet needs; presents numerical data effectively; able to read and interpret written information.
Managing People - This position has no direct reports.
Conflict Resolution - Encourages open communications; confronts difficult situations; maintains objectivity; keeps emotions under control; uses negotiation skills to resolve conflicts.
Adaptability - Adapts to changes in the work environment; manages competing demands; changes approach or method to best fit the situation; able to deal with frequent change, delays, or unexpected events. Note:
This position's scheduled work hours include weekends and holidays.
Judgement - Displays willingness to make decisions; exhibits sound and accurate judgment; supports and explains reasoning for decisions; includes appropriate people in decision-making process; makes timely decisions.
Quality - Demonstrates accuracy and thoroughness; looks for ways to improve and promote quality; applies feedback to improve performance.
Qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and/or Experience
Two years or more related experience and/or training; or equivalent combination of education and experience.
Language Skills
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
Mathematical Skills
Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry.
Reasoning Ability
Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.
Computer Skills
To perform this job successfully, an individual should have knowledge of Contact Management systems; Database software; and MS Office products software.
Certificates, Licenses, Registrations
This job does not require a specific certificate, license or registration.
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; use hands to finger, handle, or feel and talk or hear. The employee is occasionally required to stand and walk.
Work 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. The work environment is generally quiet.
