- Direct Placement
- Utilization Management
- Alhambra, CA
UM Denial Coordinator
UM Denial Coordinator ensures timely and accurate processing of all deferrals and or denials. Will ensure that all deferrals and denials are processed according to Company Policies and meet all NCQA, Health Plan, Federal and State requirements.
- Comply with Company and department policies and procedures to timely and accurately process of all deferrals and or denials.
- Review and process daily assigned deferrals or denials (denial, modify, carve out, etc.) with a minimal of 30-40 letters per day with accuracy and quality.
- Ensure UM Coordinator (level 1) and clinical reviewer has documented reason for denial.
- Ensure compliance with Turn Around Time (TAT) guidelines.
- Ensure deferrals have the specific medical records required noted along with the due date
- Call on pending deferrals to help improve response from the providers and document in the referral notes
- Ensure appropriate denial template is selected according to Health Plan, Line of Business (LOB), and threshold language.
- Ensure appropriate criteria has been selected based on hierarchy and LOB.
- Ensure that only approved criteria is utilized based on hierarchy and LOB.
- Ensure denial verbiage is at the appropriate grade level based on LOB.
- Ensure denial packet has been reviewed and completed prior to finalizing. Complete denial packets consist of the denial letter, authorization request, evidence of receipt for member/provider, clinical guidelines and medical records
- Ensure daily processing of the provider and member CCS Notification Letter
- Ensure daily Failed Fax Report for denials and deferrals is reviewed and letter/notification refaxed and documented in the referral.
- Ensure daily monitoring of the Denial Inquiry. Refax denial notification or letter, respond to provider or interdepartmental emails and document in the referral notes as needed.
- Reports to UM Denial Supervisor on activities or problems occurring throughout the day.
- Maintain a high level of integrity and confidentiality / patient privacy (HIPAA) of all information (written, verbal, electronic, etc.) that an employee encounters.
- Performs other duties, projects and actions as assigned.
- High School Graduate or equivalent.
- A minimum of one year experienced in managed care environment to include but not limited to an IPA or MSO preferred.
- Current knowledge of Managed Care UM procedures.
- Knowledge of medical terminology, RVS, CPT, HPPCS, ICD-9 codes.
- Proficient with Microsoft applications’ and EZCAP.
- Good organizational skills.
- Good verbal and written communication skills.
- Must have the ability to multitask and problem solve in a fast pace work environment
- Personal & Professional Qualities
- Punctuality, precision with details, creativity, etc. would be helpful for this position
- Ability to follow directions and perform work independently according to department standards
- Able to function effectively under time constraint
- Able to maintain confidentiality at all times
- Willingness to accept responsibility and desire to learn new task
- Ability to comply and follow company policies and procedures
- Must be a strong team player, punctual and have excellent attendance record.
$16 – $17.50