Utilization Management Coordinator II MSO
North East Medical ServiceBurlingame, CA
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Overview
Schedule
Full-time
Career level
Senior-level
Remote
On-site
Benefits
Health Insurance
Family/Dependent Health
Career Development
Job Description
The Utilization Management Coordinator II functions under the direct supervision of a physician or Registered Nurse performing utilization management (UM) and care coordination duties for the NEMS MSO. The UM Coordinator II will also provide basic training to the junior UM Coordinators.
ESSENTIAL JOB FUNCTIONS:
- Responsible to review Referral Requests and Treatment Authorization Requests received daily; process and approve authorization requests according to the NEMS MSO Authorization Grid and established clinical guidelines.
- Provide guidance to junior UM Coordinators during research of additional clinical guidelines from different sources for complex cases.
- Responsible to lead the junior UM Coordinators to prepare and present complex cases to Medical Director for review and ensure follow up activities.
- Responsible for reviewing the confirmed MD approval/modification/denial decision and notes for record tracking purposes.
- Responsible to prepare UM Notice of Action (NOA) to provider and member for UM denial decision per AB1455 turn-around-time requirement.
- Responsible for preparing UM statistical reports and submit to health plans per contract requirement.
- Perform Care Coordination activities with members, families, specialists, and ancillary providers for authorized services.
- Perform case investigation for member and/or provider complaints and appeals related to UM denials, and report findings to Health Plan.
- Provide transition of care services to members who are discharged from the hospital.
- Perform customer services for UM inquires to PCP, specialist, and members.
- Stay current with DHCS regulations, Health Plan agreements, and Industry Standard guidelines applicable to healthcare programs.
- Communicate with Health Plan for clarification about clinical guidelines for covered/uncovered benefits.
- Communicate UM related information and updates to all members of the health care team, patients, and their families.
- Follows the appropriate turnaround timeframe for decisions and notification of members and providers.
- Performs other job duties as required by manager/supervisor.
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FAQs About Utilization Management Coordinator II MSO Jobs at North East Medical Service
What is the work location for this position at North East Medical Service?
This job at North East Medical Service is located in Burlingame, CA, according to the details provided by the employer. Some roles may also include multiple work locations depending on the requirement.
What pay range can candidates expect for this role at North East Medical Service?
Employer has not shared pay details for this role.
What employment applies to this position at North East Medical Service?
North East Medical Service lists this role as a Full-time position.
What experience level is required for this role at North East Medical Service?
North East Medical Service is looking for a candidate with "Senior-level" experience level.
What benefits are offered by North East Medical Service for this role?
North East Medical Service offers following benefits: Health Insurance, Family/Dependent Health, and Career Development for this position. Actual benefits may vary depending on the employer's policies and employment terms.
What is the process to apply for this position at North East Medical Service?
You can apply for this role at North East Medical Service either through Sonara's automated application system, which helps you submit applications 10X faster with minimal effort, or by applying manually using the direct link on the job page.