UM Referral Coordinator

***This position is work from home within California.

Position Summary:

Position is responsible for following written criteria, policies and procedures in reviewing and processing daily prior authorization referrals. The position also considers eligibility, benefits, medical necessity, and appropriate providers to decide the disposition of a referral. This position has daily/weekly contact with other UM staff; Physician Reviewers and other providers; the healthplans and applicable staff; in group and out of group office staff. This position has the freedom to authorize medical services by using medical policy guidelines of the department and to process sensitive and confidential information. If the information received does not meet medical policy guidelines, this position must refer the request to an RN reviewer or a Physician Reviewer as appropriate. This position will have responsibility for working independently on assigned tasks and activities, based on established policies and procedures.

Responsibilities may include:
- Processes authorization requests according to company/department policy and within the established standards for turnaround.
- Verifies member eligibility and health plan benefits through the use of the health plan guidelines.
- Verifies specific procedures and diagnoses requested and codes them appropriately based upon CPT, ICD-10 and HCPCS codes.
- Verifies all information in EZCap and the Utilization Management workflow is correct and makes changes/updates as necessary.
- Answers all authorization inquiries in a professional and positive manner ensuring that all information given is accurate.
- Receives calls from providers or places calls to providers for additional information on authorization requests.
- Place calls to Members regarding authorization outcome.
- Composes basic letters, faxes, & emails which are sent to various providers as it relates to authorizations.
- Works collaboratively with internal departments to obtain information or documentation required to accurately process authorizations.

Minimum Qualifications:

- Three (3) or more years working in a health care or other related business environment working in authorizations, as or medical assistant (MA) and/or in medical billing services required.
- High school diploma or equivalent required.
- General knowledge of Microsoft Office applications; Excel, Word; proficient in the use of Outlook. Thorough knowledge of generally accepted professional office procedures and processes.
- General knowledge of CPT and ICD9/ICD10 and HCPCS codes as it relates to the processing of medical billing and/or authorizations.
- Familiar with medical terminology as it relates to IPA's, PPO's and HMO's.
- Ability to communicate effectively with all levels of internal/external staff, management, members, physicians/physician office staff.
- Ability to interpret and communicate complex contract or benefit language.
- Strong problem-solving abilities.
- Ability to identify issues and problems within administrative processes and other relevant areas.
- Must be attentive to detail, accurate, thorough, and persistent in following through to completion of all activities, demonstrating initiative for completing work assignments.

Preferred Qualifications:

- General knowledge of EZCap preferred.
- Completion of vocational school program in medical assisting/MA, medical front office, or medical billing and coding preferred.
- Familiarity with an electronic practice management system is preferred.
- Medical terminology preferred.
- Experience working in a managed care environment preferred.

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric, full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health’s Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups, hospitals, health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art, flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options, including medical, dental and vision plans, for the employee and their dependents, Health Spending Account (HSA), Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.

One Community. One Mission. One California