Organizational Description
The Community Health Center Network (CHCN), sister organization to the Alameda Health Consortium, is made up of the eight federally qualified community health centers in Alameda County. CHCN functions as the managed care MSO for our health centers, contracting with the Alameda Alliance for Health and Anthem Blue Cross. . In order to help our health centers meet their missions of providing the best possible care to their communities, we also provide a broad range of training, technical assistance, quality improvement, information technology, and data analytic services.
Position Title: Basic Case Management UM Coordinator I
Department: Care Management (UM)
Reports To: UM Supervisor
Classification: Non-Exempt
Status: Full-Time Regular
Salary Range: $22.45 to $27.07 hourly
Candidate must be willing to have primary residence in California. For licensing and tax purposes, we are unable to hire candidates residing outside of the state of California starting on the date of hire.
POSITION SUMMARY
The UM Coordinator I is responsible for serving primarily in an administrative support capacity and providing exceptional health care support services to the CHCN members, providers, and staff. The duties of this position include making telephone calls to members and providers serving as resource agent to internal and external customers, as well as, processing prior authorization requests within compliance guidelines.
ESSENTIAL POSITION RESULTS
The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks and responsibilities. Employees may perform other duties as assigned.
Research medical utilization management requests using a variety of resources including the Health Plans evidence of coverage, CHCN policies and procedures, industry healthcare resources and State eligibility verification systems..
Refer cases to UM Nurses, Case Managers, including the Medical Director, for clinical review, potential denial or modification.
Provide administrative and clerical support for utilization management and case management activities.
Answer questions and resolves issues promptly from members and providers pertaining to referrals, benefit verification, eligibility verifications function and authorization status and modification request.
Ensure the privacy and security of PHI (Protected Health Information) as outlined in CHCN and the Health Plans policies and procedures relating to HIPAA compliance.
Make telephone calls to members and providers according to Health Plans/CHCNs utilization management and case management protocols.
Communicate regularly via phone with health plan UM staff, providers, inpatient staff, and select government entities such as California Childrens Services.
Enter prior authorization required data in EZ-CAP or a selected database program with accuracy in a timely manner.
Adhere to Health Plans/CHCNs standards, policies, and regulations to meet Turn-Around-Time requirements for creating authorizations and delivering of denial/approval letters.
Compose denial letters in accordance to UM Nurses/Medical Directors decisions.
Coordinate activities with the other staff members of the UM & CM Department and the CHCN as a whole.
Attend and participate in required meetings.
Respond and coordinate inquiries from Customer Care to assist with provider authorization related questions.
Facilitate with CHCN Provider Relations departments on ancillary updates to OON providers and contract negotiation efforts through the LOA process.
Supports claims with verification of authorization status affecting pended and aging claims review
Provides provider education to CHCN clinic staff, ancillary providers and hospital facility in a professional and timely manner. Reports any escalation of issues to UM Supervisor for review.
Regular and reliable attendance is an essential function of the UM Coordinator I position.
Maintain current and detailed knowledge of lines of business managed by CHCN
Consistently adhere to compliance requirement regarding Turn- around Time mandates.
HIPAA Designated Access
For the purposes of the job duties of this position, the person in this position requires access only to the following HIPAA protected information data sets
1. MSO Membership2. MSO Claims3. MSO Referral/Auth.4. MSO Capitation
5. Data Warehouse6. Chart Audit/QI7. Disease Registry
SUPERVISORY RESPONSIBILITIES
None
MINIMUM QUALIFICATIONS
Competencies
Must foster a Can-Do attitude
Detail-oriented with problem-solving abilities
Excellent written and verbal communication skills, to allow for effective communication at all levels
Proficient in CPT/HCPCS and ICD-10 codes.
Organized and self-managed person with the desire to learn and the ability to work well with others.
Knowledge and application of English grammar including composition, editing and proofreading skills.
Strong organization, time management and multi-tasking abilities.
Ability to handle detailed work, work with varying types of data and maintain confidentiality.
Ability to display a courteous, patient, and helpful attitude toward co-workers at CHCN organization.
Basic understanding of Health Plans/CHCNs policies and procedures.
Essential Requirements
Minimum of one to two years previous health care experience with medical records, medical billing, or medical office experience.
Minimum of one year of experience with State and Federal insurance programs
Current Medical Assistant Certification or California Pharmacy Technician License or equivalent experience in a health care field with familiarity with medical terminology and concepts, required.
Experience in an HMO/IPA or experience in a managed care setting a plus.
High school diploma or General Education Degree (GED) required
General CHCN roles:
Foster an environment that promotes trust and cooperation among clients and staff.
Enforce policies and procedures, including maintenance of client confidentiality, to ensure that the principles of CHCN are implemented.
Be accountable for participating in decision making processes and understanding the outcome(s).
Understand the values and principles of CHCN and applies them in work responsibilities.
Participate in outreach activities, agency advocacy, and serves on ad hoc committees, as requested.
Attend and participate all required CHCN meetings.
CERTIFICATES AND/OR LICENSES
None
PHYSICAL DEMANDS
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this Job, the employee is regularly required to sit and use hands to finger, handle, or feel. The employee is frequently required to talk or hear. The employee is frequently required to stand; walk; reach with hands and arms and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision and ability to adjust focus.
WORKING CONDITIONS AND ENVIRONMENT
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly exposed to an inside environment.
The Community Health Center Network is an Equal Opportunity Employer.