Inpatient Utilization Management Coordinator / Job Req 805626180 (Information Technology)

PRINCIPAL RESPONSIBILITIES:
The Inpatient Utilization Management (UM) Coordinator will support clinical staff through completion of the administrative components of Utilization Management (concurrent, urgent, routine pre-service, as well as retrospective authorizations) and Case/Disease management (authorizations, basic care coordination). The Coordinator is responsible for processing and monitoring the authorization process and corresponding documentation continuously for quality and accuracy while working independently within a team environment. This position exercises considerable discretion and independent judgment in the performance of duties and responsibilities, including knowledge and application of appropriate resources in order to successfully complete tasks. Maintain knowledge of department policies, procedures, and regulations ensuring the department maintains turnaround times and meets regulatory requirements.
Principal responsibilities include:
Prioritize, maintain, coordinate, process accurate and timely inpatient admission, outpatient prior authorization and discharge related authorization requests (examples include acute, subacute, skilled nursing, elective surgery, DME, Home Health, Transportation, dialysis, hospice ) Assist clinical staff in transitional care services (authorizations, PCP/Specialist appointments) and case/disease management programs (authorizations, basic care coordination) within established turnaround times for compliance with policy and procedure. Utilize multiple platforms to review member eligibility status including primary, secondary, delegates. Communicate with providers and re-route requests through the appropriate method of communication. Serve as initial point of contact for operational questions and issues related to members both internally and externally; coordinate with OP UM, LTC, Case Management, Provider Services and other departments to implement solutions Maintain working knowledge of regulatory requirements for DHCS, DMHC and NCQA and apply to daily work, adhering to department workflows for Continuity of Care, in network, out of network, out of area and delegate management. Process and issue member and provider NOA notifications (mail, fax, electronic media, telephone) in accordance with regulation and standard workflows. Utilize resources and tools related to letter generation such as medical terminology glossaries, letter templates, and readability tools to generate letters in accordance with regulatory required elements. Maintain accurate documentation of internal NOA letter audits. Accurate documentation of UM activities to ensure proper claims payment with hospitals, delegates, vendors and providers Support leadership with onboarding of new team members by providing training in UM platforms, acting as a resource for new staff, and feedback to leadership. Assist leadership with external regulatory audits including DHCS, DHMC and NCQA: data gathering, file assembly and bookmarking. Excellent written, verbal and proofreading skills. Establish, facilitate and maintain effective ongoing relationships with providers including in network hospitals, and out of network hospitals and SNFs, Subacutes, home health agencies, delegated groups, vendors and providers; facilitate communication and care coordination between network entities. This includes maintaining knowledge of network and contract changes. Excellent customer service skills, ability to problem solve. Utilize established UM guideline pathways for screening, authorizing, and finalizing authorization (inpatient, outpatient, retrospective) requests. Reconcile daily hospital census reports and face sheets against plans authorization records; Maintain and communicate daily inpatient census and weekly discharge reports to hospitals. Utilize multiple electronic medical record systems in order to extract information for reviewers and working within scope. Follow protocol and process disenrollment requests: fax requests to Healthcare Options, follow up on request status, send Notice of Action and Last Covered Day letters when necessary, and escalate to compliance department when necessary. Run scheduled and ad hoc reporting on utilization data, including hold status authorizations; identify trends. Work with Medical Director, UM Management and clinical staff as well as other departments at the Alliance to receive, date, document and resolve inquiries/issues for claims, authorizations, appeals and eligibility. Perform these duties in a professional and timely manner. Receive and respond to claims issues related to an authorization. Accurately interpret and communicate member benefits and serve as resource for nurses and the IT Department in verifying and resolving member eligibility. Respond to provider, member, and staff inquiries at any given time in a professional and timely manner. Work closely with clinical personnel to better understand the reasons for modification, deferral, or denial of an authorization request. Maintain, coordinate, and prioritize authorizations to UM nurses, vendors, and hospitals in a timely manner as needed. Meet annual performance goals: individualized as well as for the healthcare services division and organization. Complete other duties and special projects as assigned.
ESSENTIAL FUNCTIONS OF THE JOB:
Communicate and coordinate with PCPs, specialists, hospitals, ancillary providers, and internal partners. Communicate effectively, both verbally and in writing. Demonstrate strong organizational and problem solving skills. Accuracy and efficiency with attention to detail a must. Demonstrate ease working in a fast-paced environment with ability to multi-task and prioritize effectively. Provide administrative support to leadership and review staff. Perform writing, administration, and data entry into multiple systems. Comply with the organizations Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
PHYSICAL REQUIREMENTS:
Constant and close visual work at desk or computer. Constant sitting and working at desk. Constant data entry using keyboard and/or mouse. Frequent use of telephone headset. Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person. Frequent lifting of folders and other objects weighing between 0 and 30 lbs. Frequent walking and standing. Occasional driving of automobiles.
Number of Employees Supervised: 0
MINIMUM QUALIFICATIONS:
EDUCATION OR TRAINING EQUIVALENT TO:
Bachelors degree or higher in a healthcare related area of study or - AS/AA degree or two (2) years of college with a minimum of one year experience making healthcare related assessments and referrals, and/or experience in working with diverse clients with multiple barriers or - High school diploma and two years of applicable experience

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
One year experience in managed care or health care setting preferred. Direct Medi-Cal experience within a managed care environment preferred Medicare and commercial experience a plus
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
Excellent verbal and written communication skills. Proof reading skills Ability to work within guidelines and protocols to achieve decisions independently. Excellent critical thinking and problem solving skills. Ability to de-escalate situations with customers and providers to achieve resolution Ability to work in cooperation with others. Ability to prioritize multiple projects as well as work for a number of other employees. Working knowledge of managed care, ancillary and hospital-based services, DME and Home Health Services.
Knowledge of medical terminology including RVS, CPT, ICD-10, and HCPCS codes. Ability to act as resource to department staff. Work collaboratively with other departments in the organization. Proficient with Microsoft Office suite.
SALARY RANGE: $95,742.40 - $143,603.20 ANNUALLY

Remote: Full Time must live in one of 6 states where we operate: CA, AZ, NV, TX, WA,OR. Available for Full-Time Work Schedule 8:00am - 5pm Pacific Time, Monday-Friday.

The Alliance is an equal opportunity employer and makes all employment decisions on the basis of merit and business necessity. We strive to have the best-qualified person in every job. The Alliance prohibits unlawful discrimination against any employee or applicant for employment based on race, color, religious creed, sex, gender, transgender status, age, sexual orientation, national origin, ethnicity, citizenship, ancestry, religion, marital status, familial status, status as a victim of domestic violence, assault or stalking, military service/veteran status, physical or mental disability, genetic information, medical condition, employees requesting accommodation of a disability or religious belief, political affiliation or activities, or any other status protected by federal, state, or local laws.