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North East Medical Services · 1 month ago

UTILIZATION MANAGEMENT COORDINATOR II MSO

Burlingame, CA

Full-time

Onsite

Entry Level

1+ years exp

North East Medical Services is seeking a Utilization Management Coordinator II to perform utilization management and care coordination duties. The role involves reviewing authorization requests, guiding junior coordinators, and ensuring compliance with clinical guidelines.

Hospital & Health Care

Responsibilities

Responsible to review Referral Requests and Treatment Authorization Requests received daily; process and approve authorization requests according to the NEMS MSO Authorization Grid and established clinical guidelines

Provide guidance to junior UM Coordinators during research of additional clinical guidelines from different sources for complex cases

Responsible to lead the junior UM Coordinators to prepare and present complex cases to Medical Director for review and ensure follow up activities

Responsible for reviewing the confirmed MD approval/modification/denial decision and notes for record tracking purposes

Responsible to prepare UM Notice of Action (NOA) to provider and member for UM denial decision per AB1455 turn-around-time requirement

Responsible for preparing UM statistical reports and submit to health plans per contract requirement

Perform Care Coordination activities with members, families, specialists, and ancillary providers for authorized services

Perform case investigation for member and/or provider complaints and appeals related to UM denials, and report findings to Health Plan

Provide transition of care services to members who are discharged from the hospital

Perform customer services for UM inquiries to PCP, specialist, and members

Stay current with DHCS regulations, Health Plan agreements, and Industry Standard guidelines applicable to healthcare programs

Communicate with Health Plan for clarification about clinical guidelines for covered/uncovered benefits

Communicate UM related information and updates to all members of the health care team, patients, and their families

Follows the appropriate turnaround timeframe for decisions and notification of members and providers

Performs other job duties as required by manager/supervisor

Qualification

Utilization managementMedical terminologyHealth Science degreeMedical Assistant CertificationAnalytical skillsFluent in EnglishFluent in ChineseCommunication skillsProblem-solving skillsOrganizational skillsTime management

Required

BS/BA Degree in Health Science or General Education highly preferred

Minimum of one year of experience in utilization management required

Recent experience in a clinic or outpatient setting desirable; able to perform efficiently and appropriately in a busy environment

Current Medical Assistant Certification or California Pharmacy Technician License or equivalent experience in a health care field is a plus

Knowledge of medical terminology is a must

Strong communication, analytical, and problem-solving skills

Knowledge of community resources and cultural needs

Good organization and prioritization skills, outstanding in time management

Must be able to fluently speak, read and write English

Preferred

Fluent in Chinese (Cantonese and/or Mandarin) preferred

Fluent in other languages is an asset

Benefits

Free medical, dental and vision insurance for employee, spouse and/or children

Company contribution to 401(k)

Company

North East Medical Services

North East Medical Services (NEMS) is one of the largest community health centers in the United States targeting the medically underserved Asian population.

Founded in 1968

San Francisco, CA, US

501-1000 employees