Authorizations Coordinator I - 26-58

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At Hill Physicians Medical Group, we’re shaping the healthcare of the future: actively managed care that prevents disease, supports those with chronic conditions and anticipates the needs of our members.

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Hill Physicians has much to offer prospective employees.  We’re regularly recognized as one of the “Best Places to Work in the Bay Area” and have been recognized as one of the “Healthiest Places to Work in the Bay Area.” When you join our team, you’re making a great choice for your professional career and your personal satisfaction.

DE&I Statement:

At PriMed, your uniqueness is valued, celebrated, encouraged, supported, and embraced. Whatever your relationship with Hill Physicians, we welcome ALL that you are.

We value and respect your race, ethnicity, gender identity, sexual orientation, age, religion, disabilities, experiences, perspectives, and other attributes. Our celebration of diversity and foundation of inclusion allows us to leverage our differences and capitalize on our similarities to better serve our communities. We do it because it's right!

Job Description:

Utilization Management Coordinator will coordinate the authorization process and support the Health Resources Management Department (HRM). This position is responsible to research, process and modify authorization requests using eligibility information, the benefit structure, and appropriate vendors in accordance with CMS, DMHC, Health Plans and Hill Physicians guidelines.

Job Responsibilities: Rotating duties in the following areas

• Enter incoming verbal, mail, and eFax (FAX COMM) requests for service using correct types and codes.

• Complete the authorization intake checklist.

• Complete authorization requests in accordance with the operational procedures outlined within the HRM Operations Manual and the Policy Provisions.

• Research and troubleshoot complex authorization rules to render the correct decision based on members benefits, a Health Plan’s contractual arrangements, and specific instructions on if a service may be authorized.

• Answer phone queue line calls in accordance with departmental standards.

• Monitor UM related Customer Service Requests (CSR) actively and respond appropriately within department standards.

• Serve as a resource to customer service.

• Overall support of the Utilization Management team (both the clinical and non-clinical) through interactions with providers, facilities and/or members.

• Maintain a current knowledge base of Utilization Management process and timelines.

• Use and document all notes pertaining to the UM function in the current Referral Management System (RMS).

• Conducts outreach calls to provider offices, collecting relevant information according to script tools, and protocols.

• Conducts member notification calls on urgent authorization requests.

• Maintain productivity and performance expectations as identified by the unit supervisor/or designee.

• Conduct calls in a courteous and customer service friendly manner.

• Creates, updates maintains and/or closes authorizations or tasks for services as assigned within client process guidelines and routes case to the appropriate associates based on established guidelines.

• Processes all incoming and outgoing correspondence/faxes in accordance with required standards and within respective timeliness guidelines.

• Refers to the appropriate clinical team members for review as defined by workflow.

• Clerical responsibilities such as processing urgent calls, mailing notifications, and document retrieval.

• Complete Notifications for services not a covered benefit per operational guidelines.

• Demonstrates a professional and courteous manner when communicating with others with the ability to state clearly and accurately the agreed upon resolution.

• Performs additional duties as assigned.

Required Experience/Skills

• The ability to learn and adhere to health plan and regulatory compliance requirements for UM.

• Excellent communication skills, both verbal and written.

• Knowledge and expertise in using Outlook email for email and scheduling.

• Data entry and computer skills in keyboard typing and navigating systems.

• Excellent organizational skills.

• Demonstrated decision-making skills.

• Initiative-taking with ability to work under direction, is flexible to change has excellent follow-through.

• Strong and proven skills in meeting quality and productivity measures.

• Strong attendance in past positions.

• Accurate use of medical terminology and codes (ICD-10, HCPC and CPT®).

• Clear and concise writing skills in accordance with healthcare documentation standards.

Preferred Experience/Skills

• Minimum 1-3 years of experience in healthcare preferred.

• Utilization Management experience preferred.

• Microsoft Excel experience preferred.

• Familiarity with the current Referral Management System (RMS)

• Customer Service skills preferred.

• Familiarity with medical terminology and experience with ICD-10, HCPC and CPT codes.

Required Education

• High school diploma or equivalent (GED).

Preferred Education/Certifications

• Medical Assistant Certification and/or 1-3 years’ experience.

• Certified Nursing Assist (CNA)

• Certified Coding Associate (CCA)

• Certified Coding Specialist (CCS)

Additional Information

Salary: $26 - $29 Hourly

Hill Physicians is an Equal Opportunity Employer