Ampcus, Inc
Utilization Management Tech - Revenue Cycle
Ampcus, Inc, Santa Monica, California, United States, 90403
SUMMARY STATEMENT:
Under the direction and supervision of the UM Assistant Manager, the
Case Management Coordinator
receives urgent, routine, pre-service and retro authorization requests and processes them through the referral and authorization procedures as established by the medical group utilization department. Responsible for prepping and processing referrals according to DOFR, posted UCLA Medical Group Medical Guidelines, identifies documents needed to assist the next level of reviewer in review, and health plan contracts. Responsible for preparation and maintenance of specific reports and computer applications/logs. Monitors those members/patients followed by Case Management. Works directly with a nurse team lead. Reviews pending claims for approval or denial.
TYPE OF SUPERVISION RECEIVED:
This position functions under the direction of the UM Assistant Manager. Work reviewed on a weekly or as needed basis as it relates to the production and quality standards established by the department. Attendance, punctuality and Ci-Care standards are monitored to ensure compliance.
ADMINISTRATIVE DUTIES
Referral processes are completed observing the UCLA Medical Group and Health Plan Policies and Procedures, Posted UCLA Medical Group Guidelines, including but not limited to the interpretation and documentation of the UCLA Medical Group Referral Matrix, benefits (if applicable), determine financial responsibility in accordance to the medical group DOFR.
Receives and processes complex referral authorization requests. Must document research and findings in electronic health record or appropriate system. Runs reports utilizing the electronic medical records or appropriate system to aid in prioritizing, processing or reporting on referrals.
Researches health plan benefit and eligibility issues for each service and enters documentation of information into the managed care electronic health record module or appropriate system.
Responsible for timely processing for all referral requests for services as per health plan requirements. Will notify supervisor in writing when unable to meet this requirement, including scanning and handling of pended referrals requiring additional review by nurse or physician.
Serves as backup to others on the Case Management Team within the UM department and is able to perform all functions of the Case Management team.
Receives telephone calls, e-mails, and all other electronic verbal or written correspondence regarding member referrals or issues. Resolves all inquiries within the same business day. May be required to document in the appropriate managed care electronic health record system. Calls members, providers and vendors to resolve issues or questions related to member referrals.
Processes daily hospital admissions and reports out-of-area hospital admissions. Documents the out-of-area admissions into the appropriate system.
Initiates and maintains medical record files for patients meeting Case Management criteria or will document in the case management module in the electronic health record or appropriate system.
Assists UM and QM Departments in the collection of information needed to respond to Appeals and Grievance cases and health plan audits.
Reviews claims referred by the Claims Department for research and determination of approval or denial on a daily basis.
Skills, Knowledge and AbilitiesREQUIREMENTS:
Ability to operate a wide variety of office equipment, including computers, printers, copy machines, facsimile receiver/transmitter, scanners and mailing equipment.
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Under the direction and supervision of the UM Assistant Manager, the
Case Management Coordinator
receives urgent, routine, pre-service and retro authorization requests and processes them through the referral and authorization procedures as established by the medical group utilization department. Responsible for prepping and processing referrals according to DOFR, posted UCLA Medical Group Medical Guidelines, identifies documents needed to assist the next level of reviewer in review, and health plan contracts. Responsible for preparation and maintenance of specific reports and computer applications/logs. Monitors those members/patients followed by Case Management. Works directly with a nurse team lead. Reviews pending claims for approval or denial.
TYPE OF SUPERVISION RECEIVED:
This position functions under the direction of the UM Assistant Manager. Work reviewed on a weekly or as needed basis as it relates to the production and quality standards established by the department. Attendance, punctuality and Ci-Care standards are monitored to ensure compliance.
ADMINISTRATIVE DUTIES
Referral processes are completed observing the UCLA Medical Group and Health Plan Policies and Procedures, Posted UCLA Medical Group Guidelines, including but not limited to the interpretation and documentation of the UCLA Medical Group Referral Matrix, benefits (if applicable), determine financial responsibility in accordance to the medical group DOFR.
Receives and processes complex referral authorization requests. Must document research and findings in electronic health record or appropriate system. Runs reports utilizing the electronic medical records or appropriate system to aid in prioritizing, processing or reporting on referrals.
Researches health plan benefit and eligibility issues for each service and enters documentation of information into the managed care electronic health record module or appropriate system.
Responsible for timely processing for all referral requests for services as per health plan requirements. Will notify supervisor in writing when unable to meet this requirement, including scanning and handling of pended referrals requiring additional review by nurse or physician.
Serves as backup to others on the Case Management Team within the UM department and is able to perform all functions of the Case Management team.
Receives telephone calls, e-mails, and all other electronic verbal or written correspondence regarding member referrals or issues. Resolves all inquiries within the same business day. May be required to document in the appropriate managed care electronic health record system. Calls members, providers and vendors to resolve issues or questions related to member referrals.
Processes daily hospital admissions and reports out-of-area hospital admissions. Documents the out-of-area admissions into the appropriate system.
Initiates and maintains medical record files for patients meeting Case Management criteria or will document in the case management module in the electronic health record or appropriate system.
Assists UM and QM Departments in the collection of information needed to respond to Appeals and Grievance cases and health plan audits.
Reviews claims referred by the Claims Department for research and determination of approval or denial on a daily basis.
Skills, Knowledge and AbilitiesREQUIREMENTS:
Ability to operate a wide variety of office equipment, including computers, printers, copy machines, facsimile receiver/transmitter, scanners and mailing equipment.
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