Utilization Management Coordinator, Lead (Inpatient)

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Utilization Management Coordinator Lead is responsible for reviewing requests for inpatient and services for all plan members. Works in collaboration with Supervisor, Utilization Management and providers to ensure timely processing of referrals to provide the highest quality medical outcomes. Leads assists and supports the management team with administrative task related to processing Utilization Management’s clinical referrals.

GENERAL DUTIES / RESPONSIBILITIES:
1.    Reviews reporting to assign tasks to Inpatient Coordinators for completion of time sensitive items.
2.    Mentors, trains, audits and coaches a team of non-clinical Inpatient Coordinator staff to ensure compliance with Alignment policies and procedure and all regulatory requirements.
3.    Provides guidance to staff or directly manage complicated coordination requests from members, providers, or staff.
4.    Participates in Inpatient quality audits including CMS program audits and vendor audits to assess timeliness of Inpatient cases. Reports audit results and identifies opportunities for process improvement
5.    Effectively communicates and keeps the Utilization Management leadership team informed of all departmental operations, activities, data, program performance, issues or any other pertinent information that would impact the overall program compliance or achievement of internal goals
6.    Assist with development of standard operating procedures (SOP) and reports
7.    Collaborates with other supervisors and managers in the department to improve processes and workflow.
8.    Act as a resource to the members, providers, and community partners
9.    Leads, initiates and follows through on multiple projects simultaneously in a team environment
10.    Other duties as assigned.

Job Requirements:

Experience:

• Required: Minimum 3+ years’ experience in a medical setting working with IPAs, entering referrals/prior authorizations. Must of have knowledge of ICD10, CPT codes, Managed Care Plans, medical terminology (certificate preferred) and referral system (Access Express/Portal/N-coder).

• Preferred: Prior Lead experience.

Education:

• Required: High School Diploma or GED.  

• Preferred: College or Technical School courses.

Training:

• Preferred: Technical School Training on Medical Terminology and Coding

Specialized Skills:

• Required:

• Knowledge of Managed Care Plans and medical terminology
• Computer Skills, 55 WPM (Microsoft Outlook, excel, word)
• Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
• Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
• Mathematical Skills:  Ability to perform mathematical calculations and calculate simple statistics correctly
• Reasoning Skills:  Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Problem-Solving Skills:  Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
• Report Analysis Skills:  Comprehend and analyze statistical reports.

Licensure:

• Required: None

• Preferred: Coding Certification, Medical Terminology

Other:

• Required: None

Essential Physical Functions:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.  While performing the duties of this job, the employee is regularly required to talk or hear. The employee