Cedars-Sinai Utilization Management Coordinator - UR/CM in Beverly Hills, California
The Utilization Management Coordinator provides support to the utilization review process. The coordinator works collaboratively with all team members of Utilization Management, Patient and Provider Services, Claims Department and other Care Coordination Department staff. In addition, the coordinator assists in identifying, tracking and coordinating services for patients when needed. The position requires strong written and communication skills and the ability to interact with Medical Directors, Providers, CSMNS members, Medical Group and IPA’s to ensure the delivery of high quality, cost effective healthcare and compliant with all state and federal regulations and guidelines.
Job Duties and Responsibilities:
Enters data and processes referral authorization requests, to include appropriate coding and quantities
Answers incoming calls from Providers, IPAs, Medical Groups and other internal and external calls and assists on the queues as needed
Monitors the Fax Inbox and appropriately distributes incoming faxes. Ensures that internal compliance security measures are met
Verifies member eligibility before processing authorizations
Identifies non-contracted providers and requests Letter-of-Agreements when requested
Requests support documentation from IPAs / Medical Groups as requested by the UM Nurses, Medical Directors, or Management
Processes Extensions and Denial Letters, when needed.
Monitors the Turn Around Timeframes
Contacts facilities identified by the UM Nurses/Manager/Director/Medical Director to research any issues (i.e. contract, discharges, services provided).
Prepare Utilization Review Reports as necessary.
Assists the Case/Care Managers in coordinating and arranging services for members.
Assists the Claims Department, when requested
Responds to variations in daily workload by evaluating task priorities according to department policies and standards.
Maintains confidentiality of information between and among health care professionals.
Other duties as assigned.
High school diploma or GED required.
One (1) years managed care experience working in an IPA, Medical Group, or health plan, a general knowledge of medical terminology, NCQA, CMS Regulations, and/or California Health and Safety Code.
Must have experience interpreting health plan and/or MCG guidelines as well.
Cedars-Sinai is an EEO employer. Cedars-Sinai does not unlawfully discriminate on the basis of the race, religion, color, national origin, citizenship, ancestry, physical or mental disability, legally protected medical condition (cancer-related or genetic characteristics or any genetic information), marital status, sex, gender, sexual orientation, gender identity, gender expression, pregnancy, age (40 or older), military and/or veteran status or any other basis protected by federal or state law.