Util Mgmt (UM) Coord (CHC)

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:

UM Coordinator will assist in the process of CHC Providers obtaining authorization, ensuring accurate data entry in the Utilization Module, and assist with requested services/treatments that do not require clinical decision making. Handles entry of all notifications of admission, transfers, and assist with the data entry of requests for home health, and durable medical equipment. They will use analytical and professional skills to answer phone calls and screen documents for key information necessary for clinical staff and Medical Directors. This will assist them in making informed medical decisions regarding admissions, transfers, services, and transports. They will also support regulatory timelines and CHC guidelines.

JOB SPECIFICATIONS AND CORE COMPETENCIES

Assists in monitoring reports and refers to appropriate UM Nurse or Manager. Data entry of requests for authorization for admissions, notification of deliveries, sick newborns, and other services. 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. Data entry and processing of fax and telephone requests to meet performance and quality standards while maintaining regulatory timeframes.

Responds to calls from the provider hotline for referral/authorization initiation and questions. Answers in a timely and professional manner. Forwards calls to appropriate nursing or medical staff as required or needed. Forwards calls efficiently to other departments when appropriate. Responsible for ensuring that provider hotline calls are answered within established regulatory time standards to minimize hold time and avoid abandoned calls. Meets required call handling standards and quality reviews.

Actively contributes to achievement of departmental goals, as identified in Department's annual business plan, including specific departmental process improvement plans and other duties as assigned.

QUALIFICATIONS:

Education/Specialized Training/Licensure: High School or equivalent

Some years of college, preferred

Work Experience (Years and Area): Three (3) years of experience Referrals/Authorization.

required.

At least one (1) year insurance related experience in managed care environment or equivalent required.

Experience in Medical Coding, preferred.

Software Proficiencies: Microsoft Office (Word, Excel, Outlook)

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