Utilization Management Coordinator II

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Day - 08 Hour (United States of America) This is a Stanford Health Care - University Healthcare Alliance job.
A Brief Overview The Utilization Management Coordinator II processes requests, monitors the authorization and utilization process and resultant documentation continuously for quality and accuracy while working independently and also with multiple departments within the organization.
The Utilization Management Coordinator II performs these duties under limited supervision and with increasing responsibility Locations Stanford Health Care - University Healthcare Alliance What you will do Authorization Process Analyze, prioritize, and prepare referral and authorization requests including inpatient admission, Outpatient/Ancillary Services requests, notice of action correspondence, fax, electronic media and phone.
Perform accurate verification of eligibility and benefits for authorization requests as well as advanced application of CPT, HCPCS, and ICD-9 codes.
Accurately review and finalize authorization requests within the Department of Managed Health Care (DMHC) and CMS mandated timeframes, using the appropriate Affinity Medical Solutions Group protocols, criteria, benefits, and clinical and administrative guidelines.
Ensure the accurate and appropriate distribution of authorization decision letters.
This includes using the appropriate DMHC or CMS-approved letter templates, using language that communicates authorization decisions clearly and accurately, and ensuring that the letters are distributed to members and providers within the appropriate timeframe's.
Run daily reports to monitor authorizations in pending statuses, hospital inpatient admissions for outlier days, and denials generated.
Accurately interpret and communicate member benefits to providers and Affinity staff verbally and in writing.
Create denial and pend notifications from standardized templates Handling Inquiries/Disputes Receive and review disputed claims that require an authorization in order to finalize, honoring the Claims timeliness standards.
Accountable for timely & accurate completion of all retro claims from the Claims Department team in accordance with the UM Business Rules Periodically respond to Member inquiries regarding authorizations in a professional and superior Customer-Service focused manner.
Work in conjunction with the Network Management and Customer Services Departments to help analyze and resolve problem situations in claims, authorizations, and eligibility.
Receive, date, and document claim inquires and appeals by telephone or mail.
This includes performing a preliminary processing and assessment of complaints and/or grievances.
Respond to multiple provider telephone inquiries in a professional and pleasant manner.
Quality Improvement Serve as an active participant in the discussions related to operational decision making processes.
Initiate and participated in group discussions with the Clinical Operations staff to review new issues or processes that require the brainstorming of the clinical and non-clinical staff, as designated by your Supervisor.
Possess the ability to create and train other staff on operational processes.
Workflow and Quality Assurance Monitors daily operations and workflow issues according to established policies and procedures.
Accountable for daily distribution of urgent authorization request report to ensure compliance with respect to communication to providers & members of request decisions Accountable for daily distribution of pend report to non-clinical UMC team for timely and accurate completion of pending requests Identify current reference sources for ongoing clinical operations issues and provide routine staff development forums.
Assists Department management team during annual health plan audit preparation & review 9.
All other duties as assigned including department-specific functions and responsibilities (1, 2): Performs other duties as assigned and participates in organization projects as assigned.
Adheres to safety, P4P’s (if applicable), HIPAA and compliance policies.
Education Qualifications 4+ years’ experience in a healthcare or two years of college and 2+ year work experience in a healthcare Experience Qualifications 2+ years’ experience in managed care authorizations and requirements Current CA Driver’s License, for potential offsite meetings and/or Provider Office Visits Required Knowledge, Skills and Abilities Training in the use of multiple system applications at once and highly accurate data entry.
Knowledge of medical terminology.
Excellent verbal and written communication skills, as well as the ability to document thoroughly within the data system.
Ability to work within established guidelines and protocols to achieve utilization management decisions independently.
Excellent critical thinking and problem solving skills.
Ability to utilize web-based resources for information retrieval purposes.
Ability to work in close cooperation with multi-disciplinary staff.
Ability to prioritize multiple projects as well as perform other duties for departments within the organization.
Working knowledge of managed care systems and regulations.
Working knowledge of CPT, ICD-9 and HCPCS codes.
Ability to act as resource and lead to other Clinical Operations Department staff.
General knowledge of ancillary and hospital based services.
Working knowledge of Healthcare Claims processes and other reimbursement systems (capitation).
Working knowledge of Healthcare operations and knowledge of the various healthcare delivery models.
Benefit interpretation and application as defined by the system.
All other duties as assigned by the Department head or Executive Management Team.
Experience in use of various system software as well as Windows, Microsoft Word, Microsoft Excel, (Microsoft PowerPoint a plus).
Licenses and Certifications CADL - California Drivers License - Valid And In State Physical Demands and Work Conditions Physical Demands Constant Sitting.
Frequent Walking.
Occasional Standing.
Occasional Bending.
Occasional Squatting.
Occasional Climbing.
Occasional Kneeling.
Seldom Crawling.
Constant Hand Use.
Constant Repetitive Motion Hand Use.
Frequent Grasping.
Occasional Fine Manipulation.
Frequent Pushing and Pulling.
Occasional Reaching (above shoulder level).
Frequent Twisting and Turning (Neck and Waist).
Constant Vision (Color, Peripheral, Distance, Focus).
Lifting Frequent lifting of 0 - 10 lbs.
Occasional lifting of 11 - 20 lbs.
Seldom lifting of 21 - 30 lbs.
Seldom lifting of 31 - 40 lbs.
Seldom lifting of 40+ lbs.
Carrying Frequent lifting of 0 - 10 lbs.
Occasional lifting of 11 - 20 lbs.
Seldom lifting of 21 - 30 lbs.
Seldom lifting of 31 - 40 lbs.
Seldom lifting of 40+ lbs.
Working Environment Occasional Driving cars, trucks, forklifts and other equipment.
Constant Working around equipment and machinery.
Seldom Walking on uneven ground.
Seldom Exposure to excessive noise.
Seldom Exposure to extremes in temperature, humidity or wetness.
Seldom Exposure to dust, gas, fumes or chemicals.
Seldom Working at heights.
Seldom Operation of foot controls or repetitive foot movement.
Seldom Use of special visual or auditory protective equipment.
Seldom Use of respirator.
Seldom Working with biohazards such as blood borne pathogens, hospital waste, etc.
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Blood Borne Pathogens Category III - Tasks that involve NO exposure to blood, body fluids or tissues, and Category I tasks that are not a condition of employment Travel Requirements 10% travel: These principles apply to ALL employees: SHC Commitment to Providing an Exceptional Patient & Family Experience Stanford Health Care sets a high standard for delivering value and an exceptional experience for our patients and families.
Candidates for employment and existing employees must adopt and execute C-I-CARE standards for all of patients, families and towards each other.
C-I-CARE is the foundation of Stanford’s patient-experience and represents a framework for patient-centered interactions.
Simply put, we do what it takes to enable and empower patients and families to focus on health, healing and recovery.
You will do this by executing against our three experience pillars, from the patient and family’s perspective: Know Me: Anticipate my needs and status to deliver effective care Show Me the Way: Guide and prompt my actions to arrive at better outcomes and better health Coordinate for Me: Own the complexity of my care through coordination Equal Opportunity Employer Stanford Health Care (SHC) strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment.
Accordingly, SHC does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity and/or expression, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above.
People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply.
Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements.
Base Pay Scale: Generally starting at $27.
47 - $35.
02 per hour The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training.
This pay scale is not a promise of a particular wage.