Utilization Management Coordinator
Our Mission is to Make Healthcare Right. Together. Built upon the belief that by connecting and aligning the best local resources in healthcare delivery with the financing of care, we can deliver a superior consumer experience, lower costs, and optimized clinical outcomes.
What drives our mission? The company values we live and breathe every day. We keep it simple: Be Brave. Be Brilliant. Be Accountable. Be Inclusive. Be Collaborative.
If you share our passion for changing healthcare so all people can live healthy, brighter lives – apply to join our team.
SCOPE OF ROLE
The role of the Referral Coordinator is to facilitate consistency of information shared across practices to promote care coordination and effective member co-management for behavioral and non-behavioral practitioners. The Referral Coordinator collaborates with clinical team members to evaluate the potential over and underutilization of specialty services based on clinical protocols.
- Prioritizes assigned patient cohorts to ensure specialty referral completion and ensures stat and expedited referrals are completed based on timeliness standards
- Schedules patients (Preferred Providers List of Specialists) and notifies them of appointment information, including, date, time, location, etc.
- Ensures missed specialty appointments are rescheduled and communicated to the physician/clinician.
- Ensures specialist notifications of referral status
- Completes exchange of information by retrieving and ensuring upload of specialty consultation and follow-up notes
- Completes documentation based on standardized documentation; to include, but not limited to location, notification of specialist, notification of patient, the status of appropriateness reviews
- Enters all Inpatient and Outpatient elective procedures in EMR and contacts specialist for post-procedure referral needs
- Follows up on all Home Health and DME orders to ensure the patient receives the services ordered.
- Completes appropriateness review based on clinical protocols and appropriately refers to Nurse or Medical Director Addresses referral-based phone calls for Primary Care Physicians panel and completed phone messages timely
- Facilitates escalation of denied referrals to the clinical team for appeal reviews.
- Adheres to the Policies and Procedures set forth by the Quality Management Committee.
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
- High School Diploma
- Minimum 2 years of experience in medical management.
- Capacity to interpret health plan benefit decisions
LICENSURES AND CERTIFICATIONS
- Certification as a Medical Assistant preferred
- The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer.
- Some travel may be required.