Utilization Management Coordinator I

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

Must reside in the state of New Jersey. Position Purpose: The Utilization Management Coordinator l may perform duties in one or more of the following areas: Prior Authorization Unit, Hospital Notification Unit, Concurrent Review Unit, Medical Review Unit or Medicare Outreach Team. The Utilization Management Coordinator l supports and coordinates intake activities in Medical Management.

All Units: Accurately and effectively applies policies, benefit and eligibility policies, procedures and standards; requesting assistance of supervisor or appropriately licensed health professional when necessary. Accurately documents all activities as per policy including entry into automated systems. Meets or exceeds established performance goals including but not limited to service, quality, productivity and turn-around time. Professionally interacts with customers, acting as a liaison between the beneficiary, provider, facility and Health Net. Maintains confidentiality of all PHI in compliance with state and federal law and Health Net Policy. Reports suspected fraud and abuse as per company policy. Performs required clerical support duties. Performs other duties as assigned Prior Authorization Unit (PCU): Answers in-coming calls and responds appropriately to phone and faxed prior authorization requests. Authorizes specifically designated services, based on company policy that do not require medical necessity review. Requests clinical records per procedure. Refers requests and notifications to appropriately licensed health professional for review. Generates letters or approval of authorizations. Hospital Notification Unit (HNU): Answers in-coming calls for hospital inpatient notification. Enters and updates Inpatient notifications into Medical Management and Vendor systems as appropriate. Performs outbound calls to Primary Provider Groups (PPGs) and Facilities for verification and /or additional information. Routes Cases to Concurrent Review UMC or RN as appropriate. Concurrent Review Unit (CCR): Provides administrative support to licensed health professionals to gather and enter pertinent information, supporting Medical Management functions for the Clinical Concurrent Review Team. Interacts with contracted providers and facilities to research issues, collect required information and/or communicate requirements or approval determinations. Performs outbound calls to PPG and Faclities to obtain discharge dispositions for one line of business. Creates and updates Discharge Dispositions for Concurrent Review admissions. Medical Review Unit (MRU): Performs non-clinical medical claim review. References CPT codes, ICD-9 codes and medical terminology Forwards clinical or medical necessity review to licensed health professionals as appropriate. Performs outbound calls to Primary Provider Groups (PPGs) for authorization verification. Enters and documents prior authorizations into appropriate claims processing system based on information provided by PPG. Responds to Service Forms (SF) for claims processing Medicare Outreach Team (MOT): Performs outbound outreach calls to members and providers in support of Medicare program and QI initiatives such as RAF, Star Ratings, etc. Answers in-coming calls related to outreach activities. Cross trains to support other Medical Management Units – PCU, HNU, CCR and MRU.