Utilization Management Tech - Revenue Cycle

Ampcus, Inc

United States, California, Santa Monica

Nov 09, 2024

SUMMARY STATEMENT:

Under the direction and supervision of the UM Assistant Manager, the Case Management Coordinator receives urgent, rountine, pre-service and retro authorization requests and processes them through the referral and authorization procedures as established by the medical group utilization department. Responsible for prepping and processing referrals according to DOFR, posted UCLA Medical Group Medical Guidelines, identifies documents needed to assist the next level of reviewer in review, and health plan contracts. Responsible for preparation and maintenance of specific reports and computer applications/logs. Monitors those members/patients followed by Case Management. Works directly with a nurse team lead. Reviews pending claims for approval or denial.

TYPE OF SUPERVISION RECEIVED:

This position functions under the direction of the UM Assistant Manager. Work reviewed on a weekly or as needed basis as it relates to the production and quality standards established by the department. Attendance, punctuality and Ci-Care standards are monitored to insure compliance.

Amount of Time	Duties and Tasks	Rating	Comments
U	M	E
	ADMINISTRATIVE DUTIES list all duties to be performed by the incumbent
	1. Referral process are completed observing the UCLA Medical Group and Health Plan Policies and Procedures, Posted UCLA Medical Group Guidelines, including but not limited to the interpretation and documentation of the UCLA Medical Group Referral Matrix, benefits (if applicable), determine financial responsibility in accordance to the medical group DOFR.
	2. Receives and processes complex referral authorization request. Must document research and findings in electronic health record or appropriate system. Runs reports utilizing the electronic medical records or appropriate system to aid in prioritizing, processing or reporting on referrals.
	3. Researches health plan benefit and eligibility issues for each service and enters documentation of information into the managed care electroninc health record module or appropiate system.
	4. Responsible for timely processing for all referral requests for services as per health plan requirements. Will notify supervisor in writing when unable to meet this requirement, including scanning and handling of pended referrals requiring additional review by nurse or physician.
	5. Serves as back up to others on the Case Management Team within the UM department and is able to perform all functions of the Case Management team.
	6. Receives telephone calls,e-mails, and all other electronic verbal or writtern coorespondance regarding member referrals or issues. Resolves all inquiries within the same business day. May be required to document in the appropiate the managed care electronic health record system. Calls members, providers and vendors to resolve issues or questions related to member referrals.
	7. Processes daily hospital admissions and reported out-of-area hosptial admissions, Documents the out-of-area admissions into the appropriate system.
	8. Initiates and maintains medical record files for patients meeting Case Management criteria or will document in the case management module in the electroinic health record or appropriate system.
	9. Assists UM and QM Departements in the collection of information needed to respond to Appeals and Grievance cases and health plan audits
	10. Reviews claims referred by the Claims Department for research and determination of approval or denial on a daily basis.

UCLA C-I-CARE/Patient Experience Practices: MY COMMITMENT TO CARE

- Act as a role model, verbally and behaviorally demonstrating skill,enthusiasm,positiveproblemsolving,commitmentandloyaltytotheprofessionandtheorganization.
- Participate in positive problem solving by providing suggestions andpossiblesolutionstoidentifiedconcerns/problems intheworkplace.

	Conduct Policy.

	INSTITUTIONAL AND/OR PROFESSIONAL STANDARDS


o Adhere to all Faculty Practice Group and UCLAMG Policies and Procedures
Knowledge and adherence to Infection Control and Environment of CareGuidelinesandProceduresasdescribedintheannualeducationmodule

Demonstrates understanding of institutional and department specificemergency management procedures/responsibilities to maintain personal,patient,andco-workersafety,maintainscompetenciesintheseareas,andparticipatesindisaster/emergencyrelatedexercisesandeducation.

Arrives to work on time and notifies supervisor when unable to reporttowork attimescheduled.

	information, reference materials and tools that are provided including via e-mail and interoffice memo, as well as updates made to pertinent policies and procedures.
	CYBERSECURITY TRAINING REQUIREMENT	N/A
	PERFORMANCE IMPROVEMENT



	OTHER DUTIES
Performs special projects and other duties as assigned or requested.

Skills, Knowledge and Abilities (Complete this section for Job Descriptions only. Disregard if used for Performance Evaluations.)
REQUIREMENTS:	List any equipment (machines, tools, office appliances or motor vehicles) required to do the job, with or without a reasonable accommodation. Indicate whether use is seldom, occasional, frequent, or constant. Ability to operate a wide variety of office equipment, including computers, printers, copy machines,facsimilereceiver/transmitter,scannersandmailingequipment.