Seasonal UM Coordinator

Description

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.  

Who Are We? ✨ 

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values. 

Why Join Us? 🏆

We’re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you’ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation. 

Job Summary

This position is responsible for providing support to the Utilization Medical Management department to ensure timeliness of outpatient or inpatient referral/authorization processing per state and federal guidelines. This position performs troubleshooting when problems situations arise and coordinates with leadership.

Functions & Job Responsibilities

• Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8:00am - 5:00pm PST.

• Review daily UM Reports for any recent activity or ‘Requested’ authorizations

• Enters data and processes referral authorization requests, to include appropriate coding and quantities

• Consistently exhibits behavior and communication skills that demonstrate Clever Care’s commitment to superior customer service with every internal and external customer

• Works with management and clinical staff for identification of members meeting qualification for Chronic Supplemental Benefit

• Answers incoming calls from Providers, IPAs, Medical Groups, and other internal and external calls and assistance in the queues as needed

• Monitors the Fax Inbox and appropriately distributes incoming faxes. Ensures that internal compliance security measures are met

• Verifies member eligibility before processing authorizations

• Identifies non-contracted providers and requests Letter-of-Agreements when needed

• Requests support documentation from IPAs / Medical Groups / Provider offices as requested by the UM/CM Nurses, Medical Directors, or Management

• Processes Extensions and Denial Letters, when needed.

• Monitors Turn Around Times

• Contacts facilities for additional information when needed

• Prepare Utilization Review Reports, as necessary.

• Assists the UM Nurses in coordinating and arranging services for members.

• Monitor daily input from Case Management for Special Supplemental Benefits Illness (SSBCI) entering authorizations and effectuation of referral to vendor.

• Responds to variations in daily workload by evaluating task priorities according to department policies and standards.

• Ability to keep all company sensitive documents secure (if applicable)

• It may be necessary, given the business need, to work occasional overtime

• Meets or exceeds productivity targets

• Maintains confidentiality of information between and among health care professionals.

• Follows all UM/CM policies and procedures

• Other duties as assigned. 

Qualifications

Qualifications

Education and Experience:

• High school diploma or general education degree (GED). AA/BA college preferred

• Minimum of 1 year experience working in a Health Plan environment, with pre-authorizations and reimbursement regulations pertaining to Medicare Advantage, Medi-Cal, Commercial Insurance, or other government programs required.

• Ability to work full time (40 hours/week) Monday - Friday. Employees are required to have flexibility to work any of our 8-hour shift schedules during our normal business hours of 8:00am - 5:00pm PST. It may be necessary, given the business need, to work occasional overtime

• Knowledge of ICD9 and CPT codes

• Knowledge of Managed Care Plans

Preferred Qualifications

• Certificate in a healthcare related field

• Experience working with IPAs

• 3 or more years of experience in a health care setting

• 1 or more years of experience performing non-clinical functions for Utilization Management reviews

• 1 or more years of experience providing supportive or direct functions for adverse determinations

Soft Skills:

• Computer literate.

• Proficient in Microsoft Office Suite, knowledge of utilization management platforms and the capacity to navigate varied health plan websites for benefit determinations.

• Broad knowledge of managed care principles

• Good oral, written and telephone skills

• Proven ability to problem-solve

• Good interpersonal skills.

•  Knowledge of medical terminology and CPT/ICD-9 coding

• Strong attention to detail

• Bilingual (Korean/English) preferred

• Ability to type 30 wpm

• Ability to manage time effectively and work independently

Wage Range: $20.00/hour - $28.00/hour, Depending on experience

Physical & Working Environment.

Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:

• Must be able to travel when needed or required  

• Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (notetaking)

• Ability to sit for extended periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.

Ability to express or exchange ideas, to impart information to the public and to convey detailed instructions to staff accurately and quickly.

Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.

#LI-Remote

Salary : $20 - $28