Job Description

The Utilization Management Coordinators are non-clinical positions, primarily responsible for processing prior authorization requests from providers to assure quality clinical outcomes for health plan members. These positions are held to strict service standards and regulatory guidelines, including timeliness and quality. The Utilization Management Coordinator II functions under the direction of the PSMR Manager, a Registered Nurse, to coordinate, generate and track both incoming and outgoing correspondence, faxes and authorizations related to pre-service, concurrent and post service review functions. Interacts with facilities, vendors, providers, and other staff to facilitate receipt of information, and /or records for prompt review and response. The Utilization Management Coordinator II has more experience and acts a resource for others, is given more complex assignments, precepts new hires and supports work distribution & team monitoring activities as needed.

Job duties include but are not limited to:

• Provides world class telephone customer service to plan members and/or providers by answering benefit questions, researching and resolving issues and inquiries and ensuring members and providers understand the Company’s products and services
• Determines contract and benefit eligibility
• Initiates and manages clinical referrals for members
• Verifies insurance coverage and obtains authorizations if needed
• Process prior authorization requests received via phone, fax or correspondence following internal policies and procedures accurately timely and with attention to detail
• Completes and appropriately forwards all authorization requests to clinicians timely for medical review
• Enters referrals and documents communications, actions and other data in departmental systems
• Provides authorization for inpatient admission, outpatient certification and/or prior authorization requests
• Demonstrates proficiency in assigned UM Coordinator activities and will perform these UM Coordinator activities to ensure unit goals are met in the face of staffing or technology concerns. Maintains access to all assigned programs and technology to ensure that they can assume any activity as needed by the unit
• Meets or exceeds all proficiency, productivity, accuracy standards set for the UM Coordinator II level
• Acts as a liaison between hospitals, physicians, health plans, vendors, patients or referral sources
• May assist supervisor with the management of daily activities over a group of UM Coordinators, including:
• Provides onboarding training for new staff, as needed
• Precept new staff for smooth post training transition and report performance issues as appropriate
• May provide guidance and expertise to less experienced UM Coordinators

Job Requirements:

• 2+ years related work experience
• High school diploma or GED
• Strong analytical skills and the ability to use sound judgment and resolve problems with minimal guidance or supervisor
• The ability to use sound judgment and resolve problems with moderate guidance from lead staff and/or supervisor
• Skills to communicate effectively to all levels of employees
• Excellent oral and written communication skills
• Excellent organizational skills
• Strong interpersonal skills
• Knowledge of medical terminology required
• Proficiency with Microsoft Office Suite (Word, Excel, Power Point)
• Familiarity with Medical management, electronic medical record and documentation programs
• Consistent word processing speed and accuracy of 50 or more words per minute

Preferred:

• Bachelor’s degree
• Knowledge/experience with NCQA Utilization Management guidelines is highly desirable
• Knowledge/experience with CMS regulatory requirements is highly desirable
• Basic understanding of LCD/NCD and overall functions of Utilization Management

General Physical Demands

Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

This position offers a hybrid work arrangement which combines flexibility with in-office engagement. Team schedules are determined based on role requirements and business needs. Travel to and from our corporate or regional offices may be required.

What We Offer:

As a Florida Blue employee, you will be at the heart of GuideWell’s vision – to lead the nation in transforming health through compassionate, connected, and technology-enabled care that delivers personalized value and empowered living.

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:

• Medical, dental, vision, life and global travel health insurance;
• Income protection benefits: life insurance, short- and long-term disability programs;
• Leave programs to support personal circumstances;
• Retirement Savings Plan including employer match;
• Paid time off, volunteer time off, 10 holidays and 2 well-being days;
• Additional voluntary benefits available; and
• A comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

Hourly Pay Range: $19 - $30

Typical Hourly Pay Range: $19 - $23

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.