The Utilization Management Coordinator I functions under the direct supervision of a physician or Registered Nurse, performing utilization management (UM) and care coordination duties for the NEMS MSO.

ESSENTIAL JOB FUNCTIONS:

• Review daily all incoming Referral Requests and Treatment Authorization Requests for inpatient and outpatient services.
• Process and approve authorization requests according to the NEMS MSO Authorization Grid and to established clinical guidelines.
• Must meet the quantitative productivity standard of 250 authorizations per week for the outpatient UM Coordinator and 115 authorizations per week for the inpatient UM Coordinator.
• For complex cases, research additional relevant clinical guidelines from different sources.
• Responsible to prepare and present complex cases to Medical Director for review; confirm Medical Director’s approval/modification/denial decision for record tracking.
• Perform Care Coordination activities with members, families, specialists, and ancillary providers for authorized services.
• Perform customer service for UM inquiries to Primary Care Physician, specialist, and members.
• Stay current with DHCS regulations, Health Plan agreements, and Industry Standard guidelines applicable to healthcare programs.
• Communicate UM related information and updates to all members of the health care team, patients, and their families.
• Follow the appropriate turnaround timeframe for decisions and notification of members and providers.
• Performs other job duties as required by manager/supervisor.

• Completion of a 2-year degree or higher.
• Knowledge of medical terminology.
• Completion of a recognized Medical Assistant degree or certificate a plus.
• Excellent data entry skills.
• Working knowledge of managed-care a plus.
• Strong communication, analytical, and problem-solving skills.
• Knowledge of community resources and cultural needs.
• Good organization and prioritization skills, outstanding in time management.
• Recent experience in a clinic or outpatient setting desirable; able to perform efficiently and appropriately in a busy environment.

• Must be able to fluently speak, read and write English.
• Fluent in Chinese (Cantonese and/or Mandarin) preferred.
• Fluent in other languages is an asset.

• This is an FLSA Non-exempt position.
• This is not an OSHA high-risk position.
• This is a full-time position.