Utilization Management Coordinator

This is a fully remote position, open to applicants in California.

📋 Description

• Assist with clinical, management, and client-related tasks that are part of the Utilization Management Program.

• Grasp and implement UM processes, including pre-authorizations, retroactive reviews, Division of Financial Responsibilities, and health plan agreements.

• Ensure that quality referrals are processed promptly in line with health plan standards.

• Adhere to UM policies and procedures while reviewing selected policies on an annual basis.

• Familiarize yourself with the NMM UM Customer Service policies and procedures.

• Process routine and urgent treatment authorization requests as outlined in the NMM Policy & Procedure Manual and UM Level 1 review process.

• Attach incoming notes to the relevant authorizations.

• Direct referrals returned from eligibility or benefits to the appropriate review queue.

• Review, screen, and manage 150–250 assigned UM referrals each day following IPA and health plan turnaround-time guidelines.

• Confirm benefit matrix through DOFR, eligibility, provider status, contracted/non-contracted status, carve-outs, and other relevant information.

• Reach out to provider offices for clarification, notes, or redirections.

• Ensure that facilities are contracted or CMS-approved when necessary.

• Handle provider and interdepartmental calls with outstanding customer service.

• Report daily activities and issues to UM Lead 3.

• Uphold strict confidentiality.

• Maintain relationships with health plans, medical directors, and external contacts.

• Support team members as necessary to achieve turnaround-time goals.

• Carry out additional duties as assigned.

⛳️ Requirements

• High School Diploma.

• A Bachelor's degree in Healthcare Administration is advantageous.

• Experience with authorizations or referrals in the healthcare sector.

• A minimum of two years' experience in a managed care setting, preferably within an IPA or MSO.

• Familiarity with medical terminology, RVS, CPT, HPCS, and ICD-9 codes.

• Proficient in Microsoft applications.

• Strong organizational abilities.

• Effective verbal and written communication skills.

• Capability to multitask and resolve issues in a fast-paced work environment.

• Punctual with a keen attention to detail.

• Ability to follow instructions and work independently in accordance with department standards.

• Excellent team collaboration skills.

• A strong attendance record.

🏝️ Benefits

• Remote position; candidates must reside in California.

• Monday to Friday schedule, typically from 8:00 am to 5:00 pm.

• Opportunity for up to 1 hour of voluntary overtime each day.

• Equal Employment Opportunity and Affirmative Action employer.

• Support for disability accommodations during the application process.