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UM Care Coord-SCMG - 2976

Job ID JR128715 Date Posted 09/16/2022
San Diego, California
  • Corporate Offices
  • Day
  • Regular
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Shift Start Time:

8 AM

Shift End Time:

5 PM

Additional Shift Information:

Weekend Requirements:

No Weekends

On-Call Required:


What You Will Do
The UM Care Coordinator, under the direct supervision of the Supervisor, Utilization Management Care Coordinators, prepares referral requests for outpatient services, elective inpatient admissions, skilled nursing facility admissions, durable medical equipment (DME), and home health, utilizing health plan web sites to obtain benefit verification information and medical necessity criteria, to be utilized by the licensed staff to determine the medical appropriateness of the requested service. This position is responsible for conducting retrospective claims review for services to determine the medical appropriateness of the provided service. Support SCMG provider practices in facilitating referrals for services for members in a timely manner in observance of regulatory requirements.

Required Qualifications
  • Other Successful completion of Medical Assistant Program or equivalent.

Preferred Qualifications
  • Other Successful completion of Medical Terminology course.
  • Other Successful completion of ICD-9 and CPT coding classes, or equivalent work experience.
  • 3 Years Experience working in the managed health care field, preferably HMO or delegated risk medical group/IPA setting.
  • 1 Year Experience with medical coding and data entry, preferably in a managed care environment.

Other Qualification Requirements
  • Microsoft Word and Excel certification preferred.

Essential Functions
  • Prior Authorization
    Obtain necessary medical/clinical information utilizing multiple sources including use of specific medical group electronic health records by following SCMG documented operational processes.
    Accurately interpret external criteria and internal operational documents.
    Ensure medical necessity criteria selected is appropriate for the referral request being reviewed.
    Document in the referral management system, according to SCMG operational processes, actions taken on each referral processed including, but not limited to telephone calls made to obtain needed information, documentation of actions taken related to the processing of the referral.
    Attach corresponding documents to the referral within the referral management system in OnBase, the document management system.
    Refer referral requests for review by licensed staff and Medical Directors within required turn-around times (TAT).
    Triage ACES Contact Us emails, Customer Service emails and CSRs, and Network Management referral requests.
    Serve as a liaison to the Care Management team and assist with obtaining requested information.
  • Benefit Verification
    Ability to proficiently navigate health plan web sites.
    Verify member eligibility status.
    Obtain detailed benefit coverage for service requests in accordance with the member's benefit plan coverage.
    Accurately interpret health plan benefits.
    Apply the benefit guidelines to approve referral requests as outlined in the SCMG prior authorization document and desktop procedures.
    Research and assist in the benefit denial process by utilizing SCMG operational documents to obtain necessary documentation, such as member specific health plan Evidence of Coverage (EOC), health plan coverage criteria, etc.
  • Retrospective Review
    Coordinate, review, and process retrospective claims for medical care and services including, but not limited to emergency room visits, urgent care visits, outpatient care, medical transportation, durable medical equipment.
    Ensure the retrospective claims review process is completed within the required regulatory turn-around times (TAT).
    Provide a determination for services that designated on the PAR document as well as the SCMG operation documents as appropriate for approval at the UM Care Coordinator level of review.
    Appropriately identify claims for review by the Medical Director to include obtaining the appropriate medically necessary criteria or benefit documents.
    Accurately complete the eMD for and forward the claim with all applicable information to the Medical Director.
  • Quality and Productivity Performance
    Achieve 90% or greater quarterly audit results.
    Complete tasks accurately with minimal supervision.
    Complete work and assigned tasks within specified timeframes.
    Maintain the established performance metric of designated average volume of referrals per day.
  • Professional Development
    Keep current knowledge and understanding of applicable accreditation and regulatory statutes related to health care, managed care, as it related to the position.
    Bring to attention of the Supervisor, Utilization Management Care Coordinators, and UM Manager, areas of UM non-compliance and provide input on actions for improvement.
    Serve as a resource and mentor to Health Services teams and other department staff.
    Establish mutually derived annual goals and meet goals.
    Maintain individual in-service/performance records.
    Attend and actively participates in department/team process/quality improvement activities.

Knowledge, Skills, and Abilities
  • Excellent working knowledge of medical terminology, CPT, ICD, HCPCS codes and its appropriate utilization use and application in referral management.
  • Knowledge of health insurance or HMO benefits.
  • Strong understanding of referral management processes.
  • Ability to present information succinctly and accurately.
  • Ability to be highly flexible, and think independently.
  • Requires excellent communication skills with the ability to communicate clearly and professionally, both verbally and in writing.
  • Ability to work independently, plan, organize, manage changes, follow directions accurately, and use resources in an organized manner.
  • Strong organizational skills with attention to detail and ability to handle and prioritize multiple conflicting priorities. Successful completion of a medical terminology course.
  • Proficiency and understanding of the following referral management applications: ACES/Optum Portal, IDX, OnBase workflows, Right Fax, and other internal tools such as eMD, for consistency, integrity and accuracy.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class

Other; Other; Other
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