Do you have compassion and a passion to help others? Transforming healthcare and millions of lives as a result starts with the values you embrace and the passion you bring to achieve your life’s best work.(sm)
The Clinical Administration Coordinator provides support to the UM department in administrative functions for UM organization determinations and appeal coordination. This position utilizes knowledge of Medicare and state HMO guidelines in order to facilitate and comply with the Utilization Management plan in data entry and to prepare letters utilizing standard templates. The Associate Patient Care Coordinator will also provide float coverage for the central UM department, utilizing and following established policies and procedures.
Primary Responsibilities:
- Provides data entry, filing, tracking time frames and status of case files and mailing letters to patients and providers
- Reviews denials and determines whether the decisions are retro/ claims DOS or prospective DOS, and whether they are NCB or medically necessary
- Sorts appropriately
- Monitors system approval queues and prints member letters, ensuring that all approvals are printed and mailed by end of business day
- Prepares envelopes and letters for mailing according the UM policy
- Receives appeal requests from health plans and/ or QIO, logs requests, researches and provides requested information
- Works with claims department to redirect claims related appeal requests.
- Generates reports for analysis by department using the data entry system
- Assists with CMS organization determination reports as needed
This is high volume, customer service environment. You'll need to be efficient, productive and thorough dealing with our members over the phone. You also must be able to work a flexible schedule that includes evening hours and Saturdays.
You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
