Utilization Management Coordinator I

**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. | ***Our commitment is to:*** Strive to a pply an equity lens to all our work. Reduce health disparities. Create an equitable work environment. | | --- | --- | **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. - Are knowledgeable of Washington Apple Health and Medicare Advantage Plans, preferred. **Essential functions and Roles and Responsibilities:** - 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. - Other duties as assigned. Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion. **Knowledge, Skills, and Abilities:** - 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. - Perform all functions of the job with accuracy, attention to detail and within established timeframes. **As part of our hiring process, the following criteria must be met:** - Complete and successfully pass a criminal background check **Criminal History:** includes review of criminal convictions an…