Utilization Management Lead

The UM Lead works under the direction of their Supervisor and UM Director to oversee day to day activities of the Referral Management Department by assisting the Medical Director and Physician Reviewers with obtaining adequate information for making referral determinations, including gathering necessary medical records, clinical review guidelines, health plan and/or regulatory policies, financial/benefit/coverage information, and/or other documentation as needed or requested.

Summary of Duties:

• Coordinates accurate and timely processing of pre-service referrals by gathering necessary medical records through use of NextGen EHR and/or contacting treating providers as necessary or requested by MD Reviewer.
• Ensures accurate eligibility and benefit verification.
• Ensures use of appropriate member notification templates.
• Facilitates timely communication of authorizations to providers, members, and health plans by monitoring the clinical review process to ensure determinations are made within the appropriate timeframe.
• Communicate with health plans when issues with coverage or responsibility are in question.
• Under the direction of the UM Manager and Supervisor, provide training and education to other UM Coordinators, Nurses, and Phisician Reviewers.
• Assist with department coverage for lunches, breaks, and absences.
• In collaboration with UM Manager and Supervisor, prepares and delivers reports, logs, and communication internally and externally.  
• Assists with development of clinical review processes to ensure workload balancing for timely and accurate workflow and production.
• Ensures consistency with member notifications by monitoring volume of clinical review queues.
• Monitors utilization patterns and notifies UM Manager and Supervisor of potential utilization issues.
• Ensures excellent customer service is provided to our members, providers, vendors, and internal customers.
• Assists with department phone coverage during normal business hours.
• Maintain up to date knowledge of MediCare, MediCal, managed care, and other insurance benefits and requirements.
• Communicate current regulations, benefits, and requirements to clinical review team and other staff as directed by UM Manager and Supervisor.
• Provide consistent clinical review updates to UM Manager and Supervisor.
• Providers resource information to patients, families, and the community when necessary.
• Creatively contributes to problem solving for outcome and process improvement.
• Assist UM Leadership with documenting situations, performance evaluations, and timecards when necessary.
• Assists meetings as needed.
• Performs other duties as assigned.

• High school graduate or equivalency.
• Ability to communicate effectively with patients, family members, vendors and providers.
• Working knowledge of Word, Excel, PowerPoint, EZ-Cap, Medic, and Report Riter.
• Must have excellent communication skills both verbally and written.
• Ability to handle a multitude of assignments, meeting all given deadlines.
• Knowledge of correct punctuation, grammar and spelling.
• Ability to deal responsibly with matters of a confidential matter.
• Ability to prioritize work in order to meet daily deadlines.
• Ability to work in a multi-task, high productive environment.
• Ability to supervise staff with varying job responsibilities and assignments.
• Ability to analyze routine statistical reports and communicate outcomes to supervisor and/or leadership as needed or assigned.
• Knowledge of inventory control and supply ordering.
• Understanding of current state and federal regulations pertaining to managed care delivery system.

The pay range for this position at commencement of employment is expected to be between $27.00 and $37.18/hr, non-exempt; however, base pay offered may vary depending on multiple individualized factors, including market location, job-related knowledge, skills, and experience. The total compensation package for this position may also include other elements, including a sign-on bonus, restricted stock units, and discretionary awards in addition to a full range of medical, financial, and/or other benefits (including 401(k) eligibility and various paid time off benefits, such as vacation, sick time, and parental leave), dependent on the position offered. Details of participation in these benefit plans will be provided if an employee receives an offer of employment.

If hired, employee will be in an “at-will position” and the Company reserves the right to modify base salary (as well as any other discretionary payment or compensation program) at any time, including for reasons related to individual performance, Company or individual department/team performance, and market factors.