Outpatient UM Coordinator


The Outpatient UM Coordinator provides effective communication between MSO, IPA providers, and members to coordinate member care. Communication to include accessibility to care, validating contract entities, and ensuring timeliness standards are met. The Outpatient UM Coordinator reports directly to the Outpatient Lead Coordinator under the guidance of the manager. 

Duties and Responsibilities

  • Process authorization requests per state and federal timeliness regulations
  • Validate data entry process for errors
  • Verify member benefits and eligibility upon receipt of treatment authorization request
  • Utilizes authorization matrix, ancillary rosters, DOFR and/or delegation agreements to drive decision-making
  • Coordinates with referral Clinician and/or Medical Director for timely processing
  • Communicate with Medical Directors to facilitate Medical Reviews for non-clinical medical review referrals
  • Outreach to members on adjudication decisions 
  • Outreach to providers offices when additional information is needed
  • Maintain knowledge of CMS & Medi-Cal policy guidelines i.e. Medicare LCD vs NCD 
  • Identify & inform Case Management Clinician on complex care diagnoses
  • Screen cases for possible California Children Services (CCS) eligible condition 
  • Read and maintain email inquiries 
  • Collaborate with other departments (i.e. Claims, PNO, etc.) to resolve member/provider matters as needed 
  • Data entry for additional requested services, as needed
  • Assist with special projects, as needed
  • Assists the Client Support Center with a high volume of calls, as needed
  • Assists other team members with their workload, as needed
  • Regular attendance at UM team meetings

Minimum Job Requirements

  • High School graduate or GED equivalent
  • One-year medical office experience
  • Knowledge of medical terminology
  • Proficiency in Microsoft Office programs, especially Word and Excel
  • Proficiency in EZCAP a plus

Skills and Abilities

  • Ability to multi-task while remaining adaptable and flexible to fast-paced environment
  • Ability to empathize with complex cases 
  • Reliable, dependable and accountable
  • Strong customer service skills with good telephone rapport
  • Self-Motivation and ability to work effectively in an independent environment 
  • Great critical thinking and problem-solving skills

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