UM Coordinator, Pre-service (Weekend Availability Required)

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.

Alignment Health is seeking an organized, detail-oriented and customer service oriented remote utilization management (UM) Coordinator to join the utilization management pre-service team. As a UM coordinator, you get to assist and support the clinical team, UM nurse, and medical director with administrative task related to processing UM's clinical referrals.

If you are hungry to learn and grow, want to be part of a growing organization, and make a positive impact in the lives of seniors – we’re looking for you!

Schedule:

This position requires weekend coverage to support turnaround time goals. Individuals must be able to work at least one weekend day as part of their regular schedule, with preference given to those who can work both Saturday and Sunday.

Potential Schedule Options (working both Sat & Sun):

Wed–Sun → Off: Mon & Tue
Thu–Mon → Off: Tue & Wed
Fri–Tue → Off: Wed & Thu
Sat–Wed → Off: Thu & Fri
Sun–Thu → Off: Fri & Sat

Potential Schedule Options (working at least one weekend day):

Tues–Sat → Off: Sun & Mon
Sun–Thurs → Off: Fri & Sat

​GENERAL DUTIES / RESPONSIBILITIES:

• Monitor fax folders.

• Verify eligibility and / or benefit coverage for requested services.

• Enter pre-service requests/authorizations in system using ICD 10 and CPT coding.

• Verify all necessary documentation has been submitted for pre-service request.

• Contact and request medical records, orders, and/or necessary documentation from requesting provider in order to process related pre-service requests/authorizations when necessary.

• Document the referral process and any pertinent determination factors within the referral system.

• Process pre-service request for medical services such as DME, office visits and radiology using approval criteria.

• Assist with mailing or faxing correspondence to PCP’s, Specialists, related to requests / authorizations as needed.

• Contact members and maintain documentation of call for Expedited requests.

• Complete tasks assigned by nurse and document accordingly.

• Answer queue calls relating to UM review and pre-service status.

• Recognize work-related problems and contributes to solutions.

• Meet specific deadlines and respond to various workloads by assigning task priorities according to department policies, standards and needs.

• Maintain confidentiality of information between and among health care professionals.

• Be a positive team player. 

Job Requirements:

Experience:

Required:

• Minimum 1 year experience in a medical setting working with IPAs, entering referrals / prior authorizations preferred.
• Knowledge of ICD10, CPT codes, Medicare Managed Care Plans, medical terminology (certificate preferred) and referral system (Access Express/Portal/N-coder).
• High school diploma or general education degree (GED) and / or training: or equivalent combination of education and experience required.
• Computer proficient
• Able to type minimum 50 words per minute (WPM)
• Experience with Microsoft Office (Word, Excel, Outlook)
• Experience with the application of UM criteria (i.e., CMS National and Local Coverage Determinations, etc.)
• Bilingual English / Spanish preferred  

Preferred:

• Medical assistant experience preferred
• Knowledge working in Access Express / Portal, Epic preferred.

Education:

Required:

• High school diploma or general education degree (GED) or (4) years' additional experience in lieu of education.

Preferred:

• Medical Terminology Certificate preferred.

Training:

Required:

Preferred:

Specialized Skills:

Required:​

• Proficient in Microsoft Office (Outlook, Excel, Word)
• Able to type minimum