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Utilization Management Coordinator

HealthSun Health Plans • Miami, FL

Posted 21 days ago

Job Snapshot

Experience - At least 2 year(s)
Healthcare - Health Services
Health Care
Relocation - No


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Job Description

HealthSun Health Plans is seeking energetic,talented and qualified professionals to join us in our mission of changing the healthcare experience of our members - making it easier, friendlier and more accessible.  If you are looking for a challenging and rewarding career with a chance to make a real difference in your community, please apply.

HealthSun Health Plans is headquartered in the Coconut Grove area of Miami, Florida supporting the needs of Medicare Advantage recipients throughout South Florida. We are proud to offer outstanding career advancement opportunities, competitive salaries, paid holidays, medical & dental insurance plans, Paid Time Off, disability benefits, and a 401(k) retirement savings plan.

The UM Coordinator position is responsible for the processing of pre-service requests along with providing administrative support to the the clinical staff.

Essential Duties & Responsibilities:
  • Answers in-coming phones calls via ACD phone lines. 
  • Data Entry/Process Referrals: Outpatient Services, in-office procedures and or visits, DME, Home Health and or any service that require Pre-Certification or to be entered for Utilization purposes. 
  • Enters authorization for hospital admissions, Skilled Nursing Facilities and Inpatient Rehabilitation.
  • Verifies referral data entry for accuracy, appropriateness and completeness. 
  • Notifies Field Case Managers of admissions and status changes for hospitalized members. 
  • Monitors and distributes all incoming and outgoing faxes.
  • Utilizes established criteria and knowledge of benefits and group contracts to determine coverage of requested services. 
  • Obtains and documents specific clinical information necessary to allow the Field Case Manager, Medical Management Manager, or Medical Director to make an informed decision/determination with regards to an admission, elective procedure and or an out of network provider. 
  • Initiates and coordinates Denial Letters and follow denial process according to Health Plan Policy and Medicare Guidelines. 
  • Focuses on achieving departmental and organizational objectives.  
  • Assists and supports other departments (Appeals & Grievance, Claims, Member Services, Provider Relations, etc.) with clerical and data entry support.
  • Obtains initial information relating to admissions, coordinates intake and enrollment processes and provides information and referrals to supervisors.
  • Communicates effectively with other professional and support staff in order to achieve positive customer outcomes.
  • Promotes and contributes to a positive, problem-solving environment.
  • Assists customers, family members and others with concern and empathy; respect their confidentiality and privacy and communicate with them in a courteous and respectful manner.
  • Complies with company policies and procedures and maintains confidentiality of customer medical records in accordance with state and federal laws.
  • Ensures compliance with all HIPAA, OSHA, and other federal, state, and local regulations. 
  • Participates in meetings, training and in-service education, as required. 
  • Performs other duties as assigned.

Job Requirements

  • Minimum of High School diploma or equivalent
  • Minimum of 2 years’ experience in the healthcare field such as a physician office or health care setting is required
  • Insurance experience in the Medicare and managed care field is preferred
  • Knowledge of ICD-10, HCPCS, CPT coding and CMS guidelines is preferred 
  • Excellent computer knowledge is required, including proficient knowledge of Microsoft Office
  • Strong decision-making and organizational skills
  • Excellent listening, interpersonal, verbal and written communication skills with individuals at all levels of the organization
  • Must be able to work with little or no supervision
  • Willingness and ability to function independently and as a team member
  • Working Knowledge of medical terminology
  • Discharge coordination experience in a managed care environment helpful 
  • Follow HIPPA guidelines
  • Ability to type at least 45 wpm
  • Ability to handle multiple functions and prioritize appropriately 
  • Ability to meet strict deadlines
  • Must be patient in dealing with an elderly population and sympathetic to hearing or vision deficiencies
  • Ability to work effectively independently and in a team environment
  • Ability to read, analyze, and interpret technical procedures or governmental regulations
  • Ability to write reports, business correspondence, and procedure manuals
  • Ability to effectively present information and respond to questions from groups of managers, clients, customers and the general public
  • Ability to calculate figures and amounts, such as discounts, interest, commissions, proportions, percentages, area and volume
  • Ability to define problems, collect data, establish facts, and draw valid conclusions
  • Strong decision-making, analytical skills
  • Must be self-motivated, organized and have excellent prioritization skills
  • Must be able to work well under stressful conditions
  • Must be able to work in a fast paced environment
  • Fluency in Spanish and English required

HealthSun Health Plans and its affiliated companies is an equal opportunity/affirmative action employer and complies with all federal and state laws, regulations and executive orders regarding affirmative action requirements in all programs.M/F/D/V.

HealthSun and its affiliates are also a drug-free workplace.

*Internal candidates must submit the Internal Application Form approved by his/her supervisor before interviewing with HR. Qualified candidates will be considered by the Hiring Manager.
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