Hours
Shift Start Time:
8 AM
Shift End Time:
5 PM
Additional Shift Information:
7AM to 6PM
Weekend Requirements:
No Weekends
On-Call Required:
No
Hourly Pay Range (Minimum - Midpoint - Maximum):
$27.986 - $34.983 - $41.979
The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.
What You Will DoThe UM Resource Coord-SCMG serves as a resource to the various teams in the SCMG UM Department. Prepares referral requests for outpatient services, elective inpatient admissions, skilled nursing facility admissions, durable medical equipment (DME), and home health, utilizing health plan web sites to obtain benefit verification information and medical necessity criteria. Support SCMG provider practices in facilitating referrals for services for members in a timely manner in observance of regulatory requirements. Responsible for UM adverse determination letters to include ensuring compliance with appropriate reading level and regulatory agency requirements. Performs clinical/medical necessity reviews and authorizes medical services that meet medical criteria. The review of care is region specific and consists of outpatient healthcare services on pre-certification requests, outpatient procedures, outpatient services, elective inpatient admissions, home health services, genetic testing, orthotics, prosthetics and complex durable medical equipment. Facilitates referrals to providers or vendors that are region specific while determining medical necessity and appropriateness.
Required Qualifications- 2 Years relevant experience in a medical setting (i.e.: office, hospital, SNF, medical clinic, etc).
- California Licensed Vocational Nurse (LVN) - CA Board of Vocational Nursing & Psychiatric Technicians -REQUIRED
Preferred Qualifications- 1 Year relevant experience in managed care.
Essential Functions - Benefit Verification
Navigates health plan web sites.
Verify member eligibility status.
Obtain detailed benefit coverage for service requests in accordance with the member's benefit plan coverage.
Accurately interpret health plan benefits.
Apply the benefit guidelines to approve referral requests as outlined in the SCMG prior authorization document and desktop procedures.
Research and assist in the benefit denial process by utilizing SCMG operational documents to obtain necessary documentation, such as member specific health plan Evidence of Coverage (EOC), health plan coverage criteria, etc. - Prior Authorization
Obtain necessary medical/clinical information utilizing multiple sources including use of specific medical group electronic health records by following SCMG documented operational processes.
Accurately interpret external criteria and internal operational documents.
Ensure medical necessity criteria selected is appropriate for the referral request being reviewed.
Document in the referral management system, according to SCMG operational processes, actions taken on each referral processed including, but not limited to telephone calls made to obtain needed information, documentation of actions taken related to the processing of the referral.
Consults with supervisor, team lead and/or medical director to discuss requests/care inconsistent to criteria and determine the appropriateness of service/care.
Attach corresponding documents to the referral within the referral management system in OnBase, the document management system.
Reviews for medical necessity and appropriateness of services/care based on health plan members medical condition, with the utilization of evidence-based criteria (MCG, Medicare, Health plan and other approved criteria)
Authorizes the correct vendor to provide care services reviewing risk matrix and health plan contracted vendor list.
Communicates decisions to the requesting provider, facility and member within department's approved guidelines.
Triage ACES Contact Us emails, Customer Service emails and CSRs, and Network Management referral requests. - Department Support
Responsible for completion of correspondence to include approval and adverse determination letters to in observance of the Flesch Kincaid reading level as required by regulation.
Complete and maintain identified standard UM reports as identified by the UM leadership team based on referral activities that are necessary for assessing and monitoring effectiveness and accuracy of managing referrals. - Communication and Time Management
Communicate effectively, both orally and in writing, with all levels of management, medical staff and patients.
Assist in conflict management and resolution as appropriate.
Manage time effectively by applying organizational, critical thinking, analytical, patient care evaluation, and problem solving techniques. - Quality and Productivity Performance
Achieve 90% or greater quarterly audit results.
Complete tasks accurately with minimal supervision.
Complete work and assigned tasks within specified timeframes.
Maintain the established performance metric of designated average volume of referrals per day. - Professional Development
Keep current knowledge and understanding of applicable accreditation and regulatory statutes related to health care, managed care, as it related to the position.
Bring to attention of leadership, areas of non-compliance and provide input on actions for improvement.
Serve as a resource and mentor to Health Services teams and other department staff.
Establish mutually derived annual goals and meet goals.
Maintain individual in-service/performance records.
Attend and actively participates in department/team process/quality improvement activities.
Knowledge, Skills, and Abilities- Knowledge of medical terminology, healthcare finances, alternative care options, utilization management, health plan criteria, established criteria such as MCG formerly known as Milliman Care Guidelines and its applications required.
- Knowledge and work experience in managed care preferred.
- Experience and knowledge of IDX and EPIC modules and systems, proficient in use of ICD-10, CPT and HCPC coding systems required.
- Proficient in typing and computer data entry (45 wpm).
Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class