Reports to: Department Manager
Department: Global Health Services
Calibrated Healthcare Network (CHN) manages over 11 million lives in over 8 states, partnering with industry leaders in the area of managed care. Our operating model features global workforce strategies, coupled with efficient technological solutions. We have a proven expertise in re-engineering complex managed care business processes to provide value to our esteemed partners. Our commitment to the evolution of healthcare is evident in our investment in research and development for the progression of dynamically enhanced technology to meet the needs of partners. The core suite of services includes Claims Adjudication, Benefits Setup, Member Enrollment and Eligibility Setup, Claims System Configuration, HCC Coding and MSO Development support.
The Calibrated Clinical Solution (CCS) global workplace is built on the concept of providing cost-effective care, enhancing population health strategies, and improving the quality of care. Calibrated Clinical Solutions deploys the use of proprietary software to create cost-effective workforce solutions constructed on the premise of collaboration technology. With our extensive domain of knowledge of managed care and dynamically enhanced technology, we have the capacity to create innovative solutions for our managed care and primary practice partners. Our core suite of services includes Medical Management, Utilization Management, Complex Case Management, and Population Health Management.
The UM Coordinator is responsible for facilitating the authorization and coordination of authorization request for inpatient and outpatient request in compliance with the client’s defined network of providers and approval criteria.
- HS Diploma required
- MA or other healthcare related Certification preferred
- 1-year managed care experience preferred
- Previous utilization management experience preferred
- Core Competencies: Ethics and Values, Customer Focus, Action-Oriented, Learning on the Fly, Manage/Measure Work, Drive for Results, Priority Setting, Timely Decision-Making, Organizing, Functional and Technical Skills
- Computer Proficiency (General browsing proficiency)
- Capacity to interpret health plan/client specific benefit guidelines, and policies/procedures
Essential Functions of Job
- Adheres to the client defined adjudication rules for UM Coordinator level of review
- Responsible for accurate member eligibility verification, member benefit verification, and network utilization to ensure accurate authorization adjudication.
- Able to accurately navigate the client-based UM platform and accurately enter referral data
- Adheres to Desktop Procedures and UM Policies and Procedures
- Effectively prepares authorization request for next level of review; to include, appropriate request of additional information, pre-certification verification, and accurate network utilization
- Consistently meets or exceeds departmental productivity standards, quality standards, and IRR.
- Compliant with turnaround timeframes for authorization adjudication and provider notification for inpatient and outpatient request.
- Ensures appropriate escalation of concerns; to include, but not limited to, Contracting issues (LOA, MOU) or Quality/Access concerns.
- Responsible outbound calls for specialty referral tracking or care gap outreach based on client service level agreements; to include assisting dependent members with making specialist appointments, timely follow-up with adherence to appointment, timely request to specialist for exchange of information with primary provider, and accurate documentation of communication.
- Ensures compliance with desktop procedures for appropriate documentation
- Performs additional duties as assigned