Remote Utilization Management (UM) Coordinator at Alignment Healthcare USA, LLC in Orange, California

Job Description:

Overview of the Role:

Alignment Health is seeking an organized, detail-oriented and customer service oriented utilization management (UM) UM Coordinator to join the utilization management team. As a UM coordinator, you get to assist and support the clinical team, UM nurse, and medical director with administrative task related to processing UM's clinical referrals.

Responsibilities:

• Monitor fax folders.
• Verify eligibility and / or benefit coverage for requested services.
• Enter pre-service requests/authorizations in system using ICD 10 and CPT coding.
• Verify all necessary documentation has been submitted for pre-service request.
• Contact and request medical records, orders, and/or necessary documentation from requesting provider in order to process related pre-service requests/authorizations when necessary.
• Document the referral process and any pertinent determination factors within the referral system.
• Process pre-service request for medical services such as DME, office visits and radiology using approval criteria.
• Assist with mailing or faxing correspondence to PCP's, Specialists, related to requests / authorizations as needed.
• Contact members and maintain documentation of call for Expedited requests.
• Complete tasks assigned by nurse and document accordingly.
• Answer queue calls relating to UM review and pre-service status.
• Recognize work-related problems and contributes to solutions.
• Meet specific deadlines and respond to various workloads by assigning task priorities according to department policies, standards and needs.
• Maintain confidentiality of information between and among health care professionals.
• Be a positive team player.

• Minimum 1 year experience in a medical setting working with IPAs, entering referrals / prior authorizations preferred.
• Knowledge of ICD10, CPT codes, Medicare Managed Care Plans, medical terminology (certificate preferred) and referral system (Access Express/Portal/N-coder).
• High school diploma or general education degree (GED) and / or training: or equivalent combination of education and experience required.
• Computer proficient
• Able to type minimum 50 words per minute (WPM)
• Experience with Microsoft Office (Word, Excel, Outlook)
• Experience with the application of UM criteria (i.e., CMS National and Local Coverage Determinations, etc.)
• Bilingual English / Spanish preferred

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
2. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.