Job Summary
The UM Care Coordinator I will coordinate with physician office staff, patients, and insurance companies to ensure that all types of insurance are verified, and services are authorized. The UM Care Coordinator I will ensure accurate, prompt, and superior service, answer phones, communicate with all departments and individuals regarding matters related to patient care, and obtain and enter accurate demographic/insurance information for all encounters including patient financial expectations. The UM Care Coordinator I will prepare referral requests for outpatient services, elective inpatient admissions, skilled nursing facility admissions, durable medical equipment (DME), and home health, utilize health plan websites to obtain benefit verification information and medical necessity criteria, to be utilized by licensed staff to determine the medical appropriateness of the requested service.
Ability to speak and read English at a level that is sufficient to satisfactorily perform the essential functions of the position. Knowledge of standard office equipment (i.e., calculator, fax, photocopier) and personal computer and computer software skills (i.e., MS Windows, Excel, Access, Word, PowerPoint, internet, e-mail). Windows computer skills including proficient use of keyboarding, use of mouse or keys for functions such as selecting items, use of drop-down menus, scroll bars, opening folders, copying and similar operations required upon employment or within the first two weeks of employment to perform the essential functions of the job. Performs other duties as assigned. Follows Palomar Health Medical Group rules, policies, procedures, applicable laws, and standards. Carries out the mission, vision, and quality commitment of Palomar Health Medical Group.
Essential Functions
Prior Authorizations: Obtain necessary medical/clinical information utilizing multiple sources including use of specific medical group electronic health records by following SCMG/PHMG documented operational processes. Accurately interpret external criteria and internal operational documents. Ensure medical necessity criteria selected is appropriate for the referral request being reviewed. Document in the referral management system, according to SCMG/PHMG operational processes, actions taken on each referral processed including, but not limited to telephone calls made to obtain needed information, documentation of actions taken related to the processing of the referral. Attach corresponding documents to the referral within the referral management system in OnBase. Refer referral requests for review by licensed staff and Medical Directors within required turn-around times (TAT). Serve as a liaison to the Case Management team and assist with obtaining requested information.
Benefit Verification: Ability to proficiently navigate health plan web sites. Verify member eligibility status. Obtain detailed benefit coverage for service requests in accordance with the member's benefit plan coverage. Accurately interpret health plan benefits. Apply the benefit guidelines to approve referral requests as outlined in the SCMG/PHMG prior authorization document and desktop procedures. Research and assist in the benefit denial process by utilizing SCMG operational documents to obtain necessary documentation, such as member specific health plan Evidence of Coverage (EOC), health plan coverage criteria, etc.
Retrospective Review: Coordinate, review, and process retrospective claims for medical care and services including, but not limited to emergency room visits, urgent care visits, outpatient care, medical transportation, and durable medical equipment supplies. Ensure the retrospective claims review process is completed within the required regulatory turn-around times (TAT). Provide a determination for services that designated on the PAR document as well as the SCMG/PHMG operation documents as appropriate for approval at the UM Care Coordinator level of review. Appropriately identify claims for review by the Medical Director to include obtaining the appropriate medically necessary criteria or benefit documents. Accurately complete the eMD for and forward the claim with all applicable information to the Medical Director.
Job Requirements
Minimum Education: High School or equivalent Preferred Education: Medical Administrative or Insurance Specialist Certified
Minimum Experience: 0-12 months in the medical field or Managed Care setting
Preferred Experience: 2 Years in healthcare setting
Required License: Not Applicable
Preferred License: Not Applicable
Required Certification: Not Applicable
Preferred Certification: Medical Administrative or Insurance Specialist Certified
We are an equal opportunity employer and do not discriminate against applicants or employees based on race, color, gender, religion, creed, national origin, ancestry, age, disability, sexual orientation, marital status or any other characteristic protected by law.
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