Remote Utilization Management (UM) Coordinator (Long-Term Temporary w\/ Medical Benefits) at Alignment Healthcare USA, LLC in Orange, California

Job Description:

Overview of the Role:

Alignment Health is seeking a remote utilization management (UM) UM Coordinator for a long-term temporary engagement (with medical benefits) to assist and support the clinical team, UM nurse, and medical director with administrative tasks related to processing utilization management's clinical referrals.

Note: Since Alignment Health is continuing to expand, there is a possibility the engagement could possibly extend and / or convert depending on budget, business need, and individual performance.

Schedule: Monday - Friday

• Pacific Time: 8am - 5pm
• Mountain Time: 9am - 6pm
• Central Time: 10am - 7pm
• Eastern Time: 11am - 8pm

• 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.
• Accurately documents referral process and any pertinent determination factors within the referral system.
• Process pre-service request for medical services such as durable medical equipment (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.
• Comply with tasks assigned by nurse and, as appropriate, documents accordingly.
• Answer queue calls relating to UM review and pre-service status.
• Recognize work-related problems and contributes to solutions.
• Meet specific deadlines (responds to various workloads by assigning task priorities according to department policies, standards and needs).
• Maintain confidentiality of information between and among health care professionals.

1. Minimum 1-year experience in a medical setting working with IPAs, entering referrals / prior authorizations preferred.
2. Knowledge of ICD10, CPT codes, Managed Care Plans, medical terminology (certificate preferred) and referral system (Access Express / Portal / N-coder) required.
3. High School Diploma or General Education Degree (GED) and / or training: or equivalent combination of education and experience required.
4. Knowledge of Medicare Managed Care Plans
5. Computer proficient
6. Able to type minimum 50 words per minute (WPM)
7. Experience with Microsoft Word, Excel, and Outlook
8. Experience with the application of UM criteria (CMS National and Local Coverage Determinations, etc.)
9. Bilingual English / Spanish preferred
10. Positive, team player