UTILIZATION MANAGEMENT COORDINATOR I MSO

The Utilization Management Coordinator I functions under the direct supervision of a physician or Registered Nurse, performing utilization management (UM) and care coordination duties for the NEMS MSO.

ESSENTIAL JOB FUNCTIONS:

- Review daily all incoming Referral Requests and Treatment Authorization Requests for inpatient and outpatient services.

- Process and approve authorization requests according to the NEMS MSO Authorization Grid and to established clinical guidelines.

- Must meet the quantitative productivity standard of 250 authorizations per week for the outpatient UM Coordinator and 115 authorizations per week for the inpatient UM Coordinator.

- For complex cases, research additional relevant clinical guidelines from different sources.

- Responsible to prepare and present complex cases to Medical Director for review; confirm Medical Director’s approval/modification/denial decision for record tracking.

- Perform Care Coordination activities with members, families, specialists, and ancillary providers for authorized services.

- Perform customer service for UM inquiries to Primary Care Physician, specialist, and members.

- Stay current with DHCS regulations, Health Plan agreements, and Industry Standard guidelines applicable to healthcare programs.

- Communicate UM related information and updates to all members of the health care team, patients, and their families.

- Follow the appropriate turnaround timeframe for decisions and notification of members and providers.

- Performs other job duties as required by manager/supervisor.