Utilization Management Coordinator I
15 days ago
Seattle
Job Description Who we are Community Health Plan of Washington is an equal opportunity employer committed to a diverse and inclusive workforce. All qualified applicants will receive consideration for employment without regard to any actual or perceived protected characteristic or other unlawful consideration. About the Role The level I UM Coordinator is responsible for administrative functions in processing Utilization Management (UM) organization determinations for services requiring authorization and hospital notification. Utilizing knowledge of Medicare and Medicaid guidelines to facilitate and comply with the UM processes in data entry of authorization requests, eligibility verification, benefit determinations, timely letter fulfilment, and support to UM clinical staff. To be successful in this role, you: • Have an associate degree, or an equivalent combination of education and highly relevant experience., • Have at least one (1) year of customer service experience, preferred., • Have working experience in a Healthcare setting, preferred., • Have working experience in a Managed Care setting, preferred., • Are knowledgeable of medical terminology and healthcare processes, preferred., • Performs data entry for all referral, prior authorizations and hospital notifications; attaches and/or includes clinical documents as needed., • Utilizes knowledge to determine appropriate CPT, HCPC, ICD-10 codes using CMS, NCQA and HCA criteria., • Researches and validates benefit and prior authorization requirements to determine appropriate course of action within the Care Management system., • Reviews, corrects, and approves authorization requests via the web portal; determines appropriate level of complexity and refers cases requiring clinical review to a nurse reviewer., • Reviews completed denial letters for accuracy and adherence to compliance deadlines. Edits and proofreads content for appropriate medical terminology and MCG criteria. Ensures letters are mailed within established timeframes., • Accurately applies policies & procedures, benefit and eligibility standards to all incoming requests., • Conducts research, validates data, and responds to complex inquiries from multiple sources, including but not limited to members, nurses, medical providers, customer service, operations, appeals, case management and care coordination. Escalating issues as needed., • Reporting to work on time and for all scheduled shifts is essential to this position., • Solid analytical skills and the ability to interpret, evaluate and formulate action plans based upon data., • Knowledge of care management workflow systems., • Effective verbal and written communication skills. Able to communicate with and collaborate effectively with physicians and allied health care providers., • Flexibility and willingness to work in a matrix-management environment., • Demonstrated organizational, time management, and project management skills., • Ability to multi-task and deal with complex assignments on a frequent basis., • Demonstrated proficiency and experience with Microsoft Office products., • Ability to work independently., • Collaborate with others in a respectful manner and ability to maintain confidentiality., • Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency, • Vaccination requirement (CHPW offers a process for medical or religious exemptions) The position is FLSA Non-Exempt and is eligible for overtime. Based on market data, this position grade is 37 (see full range below) and has a 5% annual incentive target based on company, department, and individual performance goals. The starting salary for this role is $21.00-$22.50 an hour. CHPW offers the following benefits for Full and Part-time employees and their dependents: • Medical, Prescription, Dental, and Vision, • Telehealth app, • Flexible Spending Accounts, Health Savings Accounts, • Basic Life AD&D, Short and Long-Term Disability, • Voluntary Life, Critical Care, and Long-Term Care Insurance, • 401(k) Retirement and generous employer match, • Employee Assistance Program and Mental Fitness app, • Financial Coaching, Identity Theft Protection, • Time off including PTO accrual starting at 17 days per year., • 40 hours Community Service volunteer time, • 10 standard holidays, 2 floating holidays Sensory*: • Extended periods of sitting, computer use, talking and possibly standing., • Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion., • Frequent torso/back static position; occasional stooping, bending, and twisting. Office environment Employees who frequently work in front of computer monitors are at risk for environmental exposure to low-grade radiation. *Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation. *The above is intended to describe the general content of and the requirements for satisfactory performance in this position. It is not to be construed as an exhaustive statement of the duties, responsibilities, or requirements of this position. Job descriptions may be updated or changed to reflect business needs.
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