Utilization Management Coordinator II MSO

The Utilization Management Coordinator II functions under the direct supervision of a physician or Registered Nurse performing utilization management (UM) and care coordination duties for the NEMS MSO. The UM Coordinator II will also provide basic training to the junior UM Coordinators.

ESSENTIAL JOB FUNCTIONS:

• Responsible to review Referral Requests and Treatment Authorization Requests received daily; process and approve authorization requests according to the NEMS MSO Authorization Grid and established clinical guidelines.
• Provide guidance to junior UM Coordinators during research of additional clinical guidelines from different sources for complex cases.
• Responsible to lead the junior UM Coordinators to prepare and present complex cases to Medical Director for review and ensure follow up activities.
• Responsible for reviewing the confirmed MD approval/modification/denial decision and notes for record tracking purposes.
• Responsible to prepare UM Notice of Action (NOA) to provider and member for UM denial decision per AB1455 turn-around-time requirement.
• Responsible for preparing UM statistical reports and submit to health plans per contract requirement.
• Perform Care Coordination activities with members, families, specialists, and ancillary providers for authorized services.
• Perform case investigation for member and/or provider complaints and appeals related to UM denials, and report findings to Health Plan.
• Provide transition of care services to members who are discharged from the hospital.
• Perform customer services for UM inquires to PCP, specialist, and members.
• Stay current with DHCS regulations, Health Plan agreements, and Industry Standard guidelines applicable to healthcare programs.
• Communicate with Health Plan for clarification about clinical guidelines for covered/uncovered benefits.
• Communicate UM related information and updates to all members of the health care team, patients, and their families.
• Follows the appropriate turnaround timeframe for decisions and notification of members and providers.
• Performs other job duties as required by manager/supervisor.