Utilization Management (UM) Coordinator
The Utilization Management (UM) Coordinator supports the coordination, processing, and administrative functions of the utilization review process. This role ensures timely and appropriate review of healthcare services in accordance with established guidelines and regulatory requirements, working closely with UM nurses, physicians, and other healthcare professionals.
Key Responsibilities:
• Receive, review, and process incoming requests for authorization of medical services. • Coordinate with providers, members, and internal clinical staff to gather necessary documentation for utilization reviews. • Enter authorization requests and updates into the utilization management system accurately and promptly. • Track and monitor pending authorizations to ensure timely processing and communication of decisions. • Collaborate with nurses and physicians to facilitate medical necessity reviews and ensure compliance with clinical guidelines. • Provide notification of determination (approvals or denials) to providers and members in accordance with regulatory timeframes. • Maintain accurate and organized records to ensure compliance with accreditation and regulatory bodies (e.g., NCQA, CMS, Health Plans). • Assist in audits and quality improvement activities as needed. • Serve as a liaison between internal departments, providers, and external vendors. • Ensure compliance with HIPAA and confidentiality standards at all times.
Qualifications:
High School Diploma or equivalent required; Associate's degree or healthcare certification preferred. 2+ years of experience in health plan environment; experience in utilization management or case management support strongly preferred.
Capacity To Interpret Health Plan Benefit Decisions. Bilingual Preferred (English/ Spanish) Certification As A Medical Assistant Preferred.
Skills:
• Strong knowledge of medical terminology and healthcare authorization processes. • Proficient in Microsoft Office Suite and medical management systems (e.g., , MCG, or similar UM platforms). • Excellent communication, organization, and customer service skills. • Ability to work independently and manage multiple priorities in a fast-paced environment.
Additional Information:
For individuals assigned to a location(s) in California, NeueHealth is required by law to include a reasonable estimate of the compensation range for this position. Actual compensation will vary based on the applicant's education, experience, skills, and abilities, as well as internal equity. A reasonable estimate of the range is $19.27-$28.91 Hourly.
Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; Paid Time Off, and paid holidays.