UM Coordinator - Denials

Description

• Put Patients First
• Empower Entrepreneurial Provider and Care Teams
• Operate with Integrity & Excellence
• Be Innovative
• Work As One Team

Key Responsibilities

• Adhere to Astrana Health policies and all applicable regulations, including Health Plan, DMHC, DHCS, CMS, and NCQA standards.
• Process and attach deferrals, denials, and associated documentation accurately. •Review eligibility and benefits verification. 
• Manage provider and interdepartmental communications, delivering excellent customer service. •Accurately review and process daily deferrals and denials in accordance with IPA and health plan turnaround guidelines. 
• Review and process assigned deferrals or denials (e.g., denial, modify, carve-out) in compliance with policies, accreditation, and regulatory standards. 
• Verify member eligibility, benefits, and deferral/denial requirements. 
• Maintain accurate UM/Denial system data and meet turnaround time standards. 
• Apply appropriate denial templates based on Health Plan, Line of Business (LOB), and threshold language. 
• Ensure correct criteria are used according to hierarchy and LOB, utilizing only approved standards. 
• Verify that denial verbiage is written at the appropriate reading ease and grade level based on LOB. 
• Ensure denial packets are complete before finalization, including denial letter, authorization request, proof of receipt, clinical guidelines, and medical records. 
• Assist with Failed Fax Reports, Denial Inquiries, and Appeal/Grievance Inquiries. 
• Report activities or issues to the UM Denial Supervisor/Manager throughout the day. •Maintain a high level of integrity and confidentiality, ensuring compliance with HIPAA standards. •Collaborate with UM department and participate in quality improvement initiatives. 
• Perform other duties as required to support the department. 

Qualifications

• High school diploma or GED required. 
• Knowledge of medical terminology, ICD-10, CPT, HCPCS, and RVS codes.
• Proficient in Microsoft Office and UM software (e.g., InterQual, MCG). 
• Strong organizational, decision-making, and problem-solving skills. 
• Excellent verbal and written communication. 
• Able to work effectively in a fast-paced, team environment. 
• Minimum typing speed of 40 wpm. 
• Preferred: 
  • • 2+ year with a Health Plan or MSO. 
  • Experience with health plans, managed care organizations, or hospital UM departments
  • Familiarity with Health Plan, DMHC, DHCS, CMS, and NCQA requirements. 
  • Ability to prioritize and delegate tasks effectively. 

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, this position will possibly transition to 2 days in-office and 3 days at home, per employee performance. The position is located at 1600 Corporate Center Dr, Monterey Park, CA 91754. 
• This position requires open availability M-Su 8 A - 8 P. Weekends and holidays are rotated amongst the team, and there is mandatory overtime in this position. 
• The national target pay range for this role is $21.00 - $26.00 per hour. Actual compensation will be based on geographic location (current or future), experience, and other job-related factors.