Utilization Management Coordinator I

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.

QUALIFICATIONS :

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NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

NEMS BENEFITS : Competitive benefits, including free medical, dental and vision insurance for employee, spouse and / or children; and company contribution to 401(k).