The UM Coordinator is responsible for facilitating the authorization and coordination of authorization request for inpatient and outpatient request in compliance with the client’s defined network of providers and approval criteria.
HS Diploma required
Licensure / Certification
MA or other healthcare related Certification preferred
1-year managed care experience preferred
Previous utilization management experience preferred
Core Competencies : Ethics and Values, Customer Focus, Action-Oriented, Learning on the Fly, Manage / Measure Work, Drive for Results, Priority Setting, Timely Decision-Making, Organizing, Functional and Technical Skills
Computer Proficiency (General browsing proficiency)
Capacity to interpret health plan / client specific benefit guidelines, and policies / procedures
Essential Functions of Job
Adheres to the client defined adjudication rules for UM Coordinator level of review
Responsible for accurate member eligibility verification, member benefit verification, and network utilization to ensure accurate authorization adjudication.
Able to accurately navigate the client-based UM platform and accurately enter referral data
Adheres to Desktop Procedures and UM Policies and Procedures
Effectively prepares authorization request for next level of review; to include, appropriate request of additional information, pre-certification verification, and accurate network utilization
Consistently meets or exceeds departmental productivity standards, quality standards, and IRR.
Compliant with turnaround timeframes for authorization adjudication and provider notification for inpatient and outpatient request.
Ensures appropriate escalation of concerns; to include, but not limited to, Contracting issues (LOA, MOU) or Quality / Access concerns.
Responsible outbound calls for specialty referral tracking or care gap outreach based on client service level agreements;
to include assisting dependent members with making specialist appointments, timely follow-up with adherence to appointment, timely request to specialist for exchange of information with primary provider, and accurate documentation of communication.
Ensures compliance with desktop procedures for appropriate documentation
Performs additional duties as assigned