Position Summary
The Utilization Management (UM) Coordinator is responsible for coordinating prior authorization requests, processing referrals, documenting case activity, and supporting timely utilization review activities using the EZCAP Authorization System. The coordinator ensures compliance with CMS, DHCS, NCQA, and contracted health plan requirements while maintaining excellent customer service to providers, members, and internal departments.
The UM Coordinator serves as the first point of contact for authorization requests and works closely with nurses, medical directors, case managers, provider offices, and health plans to ensure timely and accurate processing of requests.
Essential Duties and Responsibilities
Authorization Management
- Receive and process prior authorization requests through EZCAP.
- Verify member eligibility and health plan benefits.
- Verify provider participation and network status.
- Determine whether requests qualify for auto-approval.
- Create new authorization records in EZCAP.
- Enter accurate clinical and demographic information.
- Assign requests to the appropriate review queue.
- Prioritize urgent and expedited requests according to CMS requirements.
- Maintain authorization documentation throughout the review process.
- Process duplicate and corrected authorization requests.
EZCAP Responsibilities
- Create and update authorization cases.
- Document all provider communications.
- Upload supporting medical records.
- Scan and attach incoming documentation.
- Monitor pending authorization queues.
- Update authorization status throughout the review process.
- Route cases to UM Nurses and Medical Directors.
- Complete authorization closure after determination.
- Document letter mailing information.
- Verify authorization history.
Provider Communication
- Receive incoming provider telephone calls.
- Respond to fax and portal authorization requests.
- Obtain missing clinical documentation.
- Notify providers of additional information requests.
- Communicate authorization determinations.
- Escalate clinical questions to UM Nurses.
- Coordinate with provider offices regarding duplicate requests.
Documentation
Accurately document:
- Date and time of request
- Source of request
- Clinical information received
- Carve-out determination source
- Communication attempts
- Fax confirmations
- Telephone conversations
- Medical record receipt
- Provider follow-up
- Authorization status changes
Regulatory Compliance
Maintain compliance with:
- CMS Medicare Advantage regulations
- NCQA Utilization Management Standards
- DHCS Managed Care requirements
- Knox-Keene Act requirements
- Health plan contractual requirements
- Organization UM Policies and Procedures
- HIPAA Privacy and Security requirements
Turnaround Time (TAT) Monitoring
Monitor authorization turnaround times including:
- Urgent requests
- Standard requests
- Additional information requests
- Extension notifications
- Pending authorizations
- Escalations approaching regulatory deadlines
Quality Responsibilities
- Maintain complete authorization documentation.
- Follow departmental workflows.
- Meet production standards.
- Meet quality standards.
- Participate in internal audits.
- Correct identified documentation errors.
- Attend required training sessions.
- Assist with audit preparation.
Daily Responsibilities
- Review incoming authorization queue.
- Process fax requests.
- Process portal requests.
- Monitor urgent authorization requests.
- Follow up on pending cases.
- Upload clinical documentation.
- Document provider communication.
- Monitor worklists.
- Assist nurses with non-clinical tasks.
- Complete assigned production goals.
Required Knowledge
Knowledge of:
- Medical terminology
- ICD-10 diagnosis coding
- CPT/HCPCS procedure coding
- Prior authorization processes
- Medicare Advantage
- Managed Care operations
- HIPAA regulations
- CMS regulations
- NCQA standards
Knowledge of EZCAP preferred.
Required Skills
- Excellent communication skills
- Strong organizational skills
- Time management
- Attention to detail
- Data entry accuracy
- Customer service
- Critical thinking
- Multitasking
- Problem solving
- Ability to prioritize urgent work
Minimum Qualifications
Education
- High School Diploma or GED required
- Associate degree preferred
Experience
- Minimum 1 year in healthcare
- Prior authorization experience preferred
- Managed care experience preferred
- Medical office experience preferred
- Health plan experience preferred
Computer Skills
Experience with:
- EZCAP Authorization System (preferred)
- Microsoft Outlook
- Microsoft Word
- Microsoft Excel
- Adobe Acrobat
- Electronic Fax Systems
- Electronic Health Records (EHR)
- Health Plan Provider Portals
Performance Expectations
The UM Coordinator is expected to:
- Meet departmental productivity goals.
- Maintain a quality score of 95% or higher.
- Process authorizations within regulatory turnaround times.
- Accurately document all authorization activities.
- Follow all departmental policies and workflows.
- Maintain confidentiality of Protected Health Information (PHI).
- Demonstrate professionalism with providers, members, and coworkers.
AMM BENEFITS
When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:
- Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan.
- Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe.
- Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.
- Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work.
- Career Development: Tuition reimbursement to support your education and growth.
- Team Fun: Paid company outings and lunches because we work hard, but we also know how to have fun!