Utilization Management Support Coordinator Sample Job Descriptions

The utilization management support coordinator is responsible for providing support to the utilization management (UM) process. This will include assisting with reviews of medical necessity and appropriateness, providing education to members and providers, and working with internal and external stakeholders to ensure quality care. The incumbent will also develop and maintain tools and resources to support UM activities. [Your Company Name] is hiring experienced utilization management support coordinators to join our growing company and we would love to hear from you!

Typical duties and responsibilities

• Monitor the health and status of residents and patients within a facility to ensure that they are receiving proper care
• Train employees within the hospital to develop the right care plan
• Perform administrative duties such as monitoring the discharge process and ensuring that clinical documentation is done accurately
• Participate in inspections of the healthcare facility
• Make recommendations on how the nursing service department can be improved
• Monitor changes in federal and state healthcare laws and ensure compliance

Education and experience

• Bachelor’s degree in social work, psychology, counseling, or a closely related field required
• An associate’s or bachelor’s degree in nursing and a passing score on the NCLEX-RN licensing exam is often required as well

Required skills and qualifications

• Strong project management skills
• Excellent presentation and communication skills
• Robust assessment, analytical, and computer skills

Preferred qualifications

• Develop and maintain tools and resources to facilitate the UM process
• Provide education on the UM process, coverage, coding requirements, and medical necessity to members and providers
• Assist with reviews of medical necessity and appropriateness
• Work with internal and external stakeholders to ensure quality care

ABC Company Clinical Effectiveness (Authorization) Unit is primarily responsible for the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of ABC Company’s benefits plan. The Utilization Management (UM) Support Coordinator is responsible for applying clinical and benefits administration policy guidelines to requests for authorizations. The UM Support Coordinator provides accurate, prompt, and appropriate medical authorizations to requests from ABC Company Clinicians, Vendors, and Providers.

Responsibilities

• The UM Support Coordinator reports to the Utilization Management Nurse Manager
• Uses established criteria to conduct preliminary decision review for services requiring prior authorization
• Applies clinical and benefit administration policy guidelines to requests for authorizations
• Assesses the need for additional information to complete a service decision request
• Enters authorizations into ABC Company’s data system to ensure timely review of and downstream claims processing
• Works closely with UM RN staff to escalate decisions that require clinical review and oversight
• Communicates results of reviews in the centralized enrollee record for the primary care team and clinical reviewers
• Handles all authorization requests timely and accurately, adhering to performance measures
• Follows department and organizational policies and procedures as well as adheres to all applicable regulatory, contractual, and compliance requirements
• Fulfills duties as above within service standard turnaround times

Qualifications

• Associate’s Degree or equivalent experience – Bachelor’s Degree
• 2+ years professional work experience in health care, managed care, or insurance
• Education, training or experience as a medical coder, medical billing, Insurance Coordinator or other relevant clinical background highly preferred
• Familiarity with utilization management review
• Knowledge of CPT and ICD coding highly preferred
• Flexibility and understanding of individualized care plans
• Excellent interpersonal, verbal, and written communication skills
• Ability to work independently and make decisions
• Work in a team based environment
• Working knowledge of and ability to navigate through the healthcare system (insurances, Medicare, Medicaid, physician office operations)
• English required, bilingual preferred

This position is responsible for providing support to the Medical Management department to ensure timeliness of outpatient or inpatient referral/authorization processing per state and federal guidelines. This position performs trouble-shooting when problems situations arise and takes independent action to resolve complex issues.

Responsibilities

• Input data into the Medical Management system to ensure timeliness of referral/authorization processing
• Verifies member benefits and eligibility upon receipt of the treatment authorization request
• Utilizes authorization matrix, ancillary rosters, DOFR, and/or delegation agreements to drive decision-making
• Coordinates with referral nurse and/or Medical Director for timely referral processing
• Ensure timely provider and member oral and written notification of referral decisions
• Ensures proper notification of patient facility admissions with PCP and NOMNC when applicable
• Coordinate board certified referrals with partner vendors
• Coordinates and assists with patient appointments as needed and notify patient of authorization status
• Performs trouble-shooting when problems situations arise; taking independent action to resolve complex issues
• Prepares denial letters for review by Medical Director or Nurse Reviewer(s) and distributes letters to appropriate recipients
• Performs coordination for out-of-network cases and facilitates letters of agreement (LOA) processing in collaboration with Medical Directors and Leadership
• Performs coordination of benefits
• Demonstrates excellent communications skills and interpersonal relationships
• Collaborates and facilitates interdisciplinary team communications
• Perform additional duties as assigned
• Process referrals and/ or calls within the dept. targets based on workflows and technology
• Meets inter-rater minimum standards for core responsibilities
• If assigned to Provider Phone Queues, Collaborates with Customer Service Representatives to provide information regarding referral/authorization processing
• Appropriately tracks incoming call types and pertinent details of calls

Qualifications

• High School Diploma or equivalent required
• MA or Medical Billing Certificate preferred
• Minimum 2 years of experience working in a medical billing environment (IPA or HMO preferred), with pre-authorizations and reimbursement regulations pertaining to Medi-Cal, CCS, and other government programs required
• Prior experience in utilization management processing authorization referrals also required
• Prefer prior Lead position experience

Purpose

Supports the Utilization Management clinical teams by assisting with non-clinical administrative tasks and responsibilities related to pre-service, utilization review, care coordination, and quality of care.

Responsibilities

• Performs member or provider related administrative support which may include benefit verification, authorization creation and management, claims inquiries, and case documentation
• Reviews authorization requests for initial determination and/or triages for clinical review and resolution
• Provides general support and coordination services for the department including but not limited to answering and responding to telephone calls, taking messages, letters and correspondence, researching information, and assisting in solving problems
• Assists with reporting, data tracking, gathering, organization and dissemination of information such as Continuity of Care process and tracking of Peer to Peer reviews

Qualifications

Education Level: High School Diploma

Experience: 3 years experience in health care claims/service areas or office support

Preferred Qualifications

• Two years experience in health care/managed care setting or previous work experience within division
• Knowledge of CPT and ICD-10 coding

Knowledge, skills and abilities

• Ability to effectively participate in a multi-disciplinary team including internal and external participants
• Excellent communication, organizational and customer service skills
• Knowledge of basic medical terminology and concepts used in managed care
• Knowledge of standardized processes and procedures for evaluating medical support operations business practices
• Excellent independent judgment and decision-making skills, consistently demonstrating tact and diplomacy
• Ability to pay attention to the minute details of a project or task
• Experienced in the use of web-based technology and Microsoft Office applications such as Word, Excel, and PowerPoint
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging