UM Coordinator San Jose, CA
Job description
SUMMARY
Under the general direction of the UM Lead, Monitor, this TEMP to HIRE position documents provider and member inquiries through inbound/outbound calls and processes provider and member notification of authorization decisions/requests for information to meet regulatory time frames. Works closely with nursing staff, member services, and compliance as well as external health plans and providers to follow up on incoming authorizations and obtain necessary documentation for timely determinations. Promotes and provides excellent customer service. Conducts all aspects of job performance and judgement in an ethical and confidential manner. Accurate data entry, tracking, and organization are a must. The successful candidate will have strong communication, time management, and organization skills.
ESSENTIAL DUTIES AND RESPONSIBILITIES
1. Assists with monitoring, coordinating, and executing the day-to-day workflow for prior authorization processing. This includes intake, review, system updates, notice generation, etc. to ensure timely, compliant processing.
2. Reviews prior authorization request forms for correctness and completeness. Communicates with providers and facilities to gather required medical documentation for authorization requests. Ensures regulatory compliance with turnaround times and appropriate notification to members and providers. Communicates with hospitals and facilities to request clinical documentation for initial review of members.
3. Works with team to manage the UM phone queue during business hours. Professionally manages callers in a diplomatic and tactful manner and appropriately escalate complaints for resolution. Delivers exemplary service to members, their families, physicians, providers, and internal customers. Directs member care within contracted network, whenever appropriate.
4. Consistently performs accurate data-entry into system software applications for utilization management. Contributes to the effectiveness and efficiency of the department. Utilizes reports and systems to identify and monitor utilization resource patterns and support quality improvement.
5. Assists with training new and existing staff regarding prior authorization process and workflow. Assists in developing and maintaining training and desktop resources.
6. Consistently demonstrates dependability and timely completion of all duties and assignments.
7. Performs other duties, projects or functions as assigned.
QUALIFICATIONS:
Associate’s degree, Bachelor’s degree, or equivalent experience in healthcare required.
A minimum of one year of compliance/regulatory experience
- A minimum of one year working in managed healthcare.
- Ability to interpret regulations and laws and disseminate information.
- Ability to use independent, ethical judgment and to impart confidential information.
- Demonstrated knowledge of medical terminology and medical coding.
- Excellent verbal and written communication skills.
- Strong organization, time management, and attention to detail.
- Ability to concentrate without distraction in a fast-paced environment; Adapt to a rapidly changing environment and keep supervisor informed of any delays which could disrupt delivery of services or internal operations.
- Demonstrated results-oriented skills.
- Demonstrated self-motivation; Ability to work independently with minimal supervision, assume responsibility, take initiative, follow up on assignments, make decisions when appropriate, handle multiple projects simultaneously, and assume accountability for work.
- Ability to build strong internal and external relationships.
- Demonstrated excellent customer service skills.
- Strong working knowledge of standard software applications such as Microsoft Outlook, Word, and Excel; Willing to learn applicable computer programs.
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.
- While performing the duties of this position, the employee is regularly required to sit and use hands to finger, handle, or feel objects, tools or controls. The employee is frequently required to reach with hands and arms and talk or hear. The employee is occasionally required to walk.
- The employee must be able to lift and move up to 10 pounds. Specific vision abilities required by this position include close vision, color vision and the ability to adjust focus.
- Nothing in this job description restricts management’s right to assign or reassign duties and responsibilities to this job at any time.
COVID-19 considerations:
We currently follow the SCCPH guidelines for COVID-19
Job Type: Full-time
Pay: $26.00 - $29.00 per hour
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Disability insurance
- Employee assistance program
- Flexible spending account
- Health insurance
- Life insurance
- Paid time off
- Tuition reimbursement
- Vision insurance
Schedule:
- 8 hour shift
- Monday to Friday
- Weekend availability
Ability to commute/relocate:
- San Jose, CA 95131: Reliably commute or planning to relocate before starting work (Required)
Experience:
- Customer service: 3 years (Preferred)
- Medical terminology: 3 years (Preferred)
- Computer skills: 5 years (Preferred)
Work Location: One location
