PACE Utilization Management Coordinator I

July 1, 2022July 1, 2022 | | 0 Comment | 12:30 am

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.
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