Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
' Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
' Children's Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
' Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
' Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
JOB SUMMARY:
The UM Coordinator II is primarily responsible for identifying and resolving any missing information from Inpatient Clinicals and prior authorization requests, assisting with training new hires and completing all non-clinical tasks pertaining to prior authorizations, concurrent reviews, and providing general assistance to UM Leadership and UM Coordinator Team. This position is responsible for the initiation of requests for authorization by entering clinical, demographic, and product information into the Medical Management system, received via phone, fax, or online portal, and accurate case creation and completion, maintaining quality and productivity standards. The UM Coordinator II electronically routes cases to the nursing team for review, assisting the nursing team with administrative tasks to include but not limited to fax notifications and out of network requests
JOB SPECIFICATIONS AND CORE COMPETENCIES
Completes all non-clinical tasks as assigned pertaining to prior authorizations and concurrent requests including but not limited to auto approvals, out of network request, and sending correspondence to the provider. Obtains all pertinent information and medical codes related to the admission, transfer, out of network provider, route of transport, type of service, type of durable medical equipment and other key information for data entry of admissions, notification of deliveries, sick newborns, and other services.
Reviews and processes fax and telephone requests to meet departmental key metrics and productivity standards, maintain established threshold for case data entry and accuracy within compliance timeframes. Identifies and resolves any missing information regarding Inpatient clinical and prior authorization requests to ensure turnaround times are met.
Demonstrates understanding of turnaround compliance, process improvements, sharing and supporting tasks and training with the UM Leadership team as well as performing UM Coordinator duties. Assists with training of new UM Coordinators.
Actively contributes to achievement of departmental goals, as identified in Departments annual business plan, including specific departmental process improvement plans and other assigned duties.
QUALIFICATIONS:
Education/Specialized Training/Licensure: High School Diploma or equivalent.
Associates preferred.
Work Experience (Years and Area): Associates and two (2) years related work experience or four (4) years' experience in lieu of degree.
Medicaid coding and Managed Care required.
Preferred experience in healthcare setting such as a medical clinic, hospital, or managed care.
Software Proficiencies: Microsoft Office (Word, Excel, Outlook)
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