Job Description
Job DescriptionDescriptionAstrana Health is seeking a dedicated Utilization Management (UM) Coordinator to support the UM department in reviewing, monitoring, and processing prior authorization requests while ensuring compliance with regulatory standards and health plan guidelines. The UM Coordinator will serve as a key liaison between providers, members, and internal clinical staff, delivering excellent customer service and ensuring accurate documentation and timely processing of referrals. This role is responsible for coordinating and documenting medical review activities to confirm that services meet established criteria for medical necessity, appropriateness, and efficiency, while facilitating clear and timely communication across all stakeholders.
Our Values:
- Put Patients First
- Empower Entrepreneurial Provider and Care Teams
- Operate with Integrity & Excellence
- Be Innovative
- Work As One Team
What You'll Do
- Comply with UM policies and procedures. Annual review of selected UM policies.
- Read and understand NMM UM Customer Service Policy and Procedures
- Process Routine & Urgent treatment authorization requests according to the NMM Policy & Procedure Manual based on UM Level 1 review process.
- Assist with attaching incoming notes to appropriate authorizations
- Move referrals coming back from eligibility and or benefits to the correct queue for review
- Accurately review, screen and process daily assigned UM referrals (avg 150-250) in accordance with IPA and health plan TAT guidelines
- Responsible for verification to include but not limited to: benefit matrix through DOFR, eligibility, provider status (contracted/non-contracted), carved out and others.
- Contact providers office as needed for clarification, notes or redirections
- Verify that facilities are contracted and or a CMS approved facility when required.
- Attend to provider and interdepartmental calls in accordance with exceptional customer service
- Reports to UM Lead 3 on activities or problems occurring throughout the day.
- Maintains strictest confidentiality at all times.
- Maintain good relationships with health plans and medical directors and external contacts.
- Team skills, assist others as needed in order to comply with TAT.
- Other duties as assigned
Qualifications
- High School Graduate, Bachelor's in Healthcare Administration is a plus
- At least 2 years of experienced in managed care environment to include but not limited to an IPA or MSO preferred
- Knowledge of medical terminology, RVS, CPT, HPCS, ICD-9 codes
- Proficient with Microsoft applications, EZCAP preferred
- Good organizational skills, verbal and written communication skills
- Ability to multitask and problem solve in a fast pace work environment
- Punctuality and detail-oriented
- Ability to follow directions and perform work independently according to department standards
- Must be a strong team player and have excellent attendance record
Environmental Job Requirements and Working Conditions
- This is a hybrid position. The position will be fully in-office for 3 month probationary period. After successful completion of probationary period, position will transition to 2 days in-office and 3 days at home. The position is located at 1600 Corporate Center Dr, Monterey Park, CA 91754.
- This position requires open availability between M-Su, 8 A - 8 P. You would be scheduled for 5 shifts a week, weekends and holidays are rotated amongst the team, and there is overtime in this position!
- The national target pay range for this role is $21.00 - $24.00 per hour. Actual compensation will be based on geographic location (current or future), experience, and other job-related factors.
Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation.
Additional Information:
The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.