PACE Utilization Management Coordinator I

Overview

This position is responsible for providing support to the Senior Care Services/PACE department to ensure timeliness of outpatient or inpatient referral/authorization processing per state and federal guidelines. This position performs trouble-shooting when problems situations arise and coordinates with leadership.

Responsibilities

Input data into the referral management system to ensure timeliness of referral/authorization processing.

Verifies member benefits and eligibility upon receipt of the treatment authorization request.

Utilizes authorization matrix, ancillary rosters, DOFR, and/or delegation agreements to drive decision-making.

Coordinates with referral nurse and/or Medical Director for timely referral processing.

Ensure timely provider and member oral and written notification of referral decisions.

Creates Custodial authorizations by coordinating with site IDT and distribute authorization to the site IDT or the nursing facility as needed to assist with coordination of admission.

Assist with modification of custodial authorization with needed codes including extension of authorization upon expiration date

Closes all custodial authorization upon notification from the site IDT regarding patients discharge status.

Process all skilled nursing facility authorizations

Utilizing Customer service module coordinates with LOA department and specialist office to assure all the LOA requests are processed in a timely manner and communicate the approval status with the site IDT.

Utilizing Customer service module, respond to all outside specialist office and PACE scheduler inquires and resolve issues on daily basis.

Ensures proper notification of patient facility admissions with PCP/PACE site when applicable.

Coordinate board certified referrals with partner vendors.

Coordinates and assists with patient appointments as needed and notify patient of authorization status.

Performs trouble-shooting when problems situations arise and coordinates with leadership.

Prepares denial letters for review by Medical Director or Nurse Reviewer(s) and distributes letters to appropriate recipients.

Demonstrates excellent communications skills and interpersonal relationships.

Collaborates and facilitates interdisciplinary team communications.

Perform additional duties as assigned.

Process referrals within the dept. targets based on workflows and technology.

Meets performance and quality performance standards for core responsibilities.

Qualifications

High School Diploma or equivalent required.

MA or Medical Billing Certificate preferred.

Minimum 1 year of experience working in a medical billing environment (IPA or HMO preferred), with pre-authorizations and reimbursement regulations pertaining to Medi-Cal, CCS and other government programs required.

Prior experience working in a clinic/health care specialty call center.

Prefer experience in utilization management processing authorization referrals.

PACE Utilization Management Coordinator I

Overview

Responsibilities

Qualifications

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