Job Description

TEMPORARY POSITION

FLSA Status: Non-Exempt
Department: Health Services
Reports To: Supervisor, Utilization Management

GENERAL DESCRIPTION OF POSITION

The Medical Management Care Coordinator I performs non-clinical supportive duties related to utilization management (UM) and care coordination for Santa Clara Family Health Plan (SCFHP) members. Routine supportive duties include but are not limited to data entry into system software applications, managing department telephone queues, and assisting with quality monitoring projects for both SCFHP lines of business in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, Care Coordinator Guidelines and business requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

1. Follow established Health Services policies and procedures and use available resources to respond to member and/or provider inquiries and resolve any concerns in an accurate, timely, respectful, professional and culturally competent manner
2. Collaborate with team members on improvement efforts across-departments regarding quality improvement projects, optimization of utilization management, and member satisfaction.
3. Develop effective and professional working relationships with internal and external stakeholders and partners. Communicate effectively with members and providers orally and in writing.
4. Assist in gathering and processing data for internal required reports and analysis.
5. Attend and actively participate in daily, weekly, and monthly departmental meetings, in-services, training and coaching sessions.
6. Follow UM policies and processes to the management of incoming authorization requests received through fax, mail or telephone.
7. Identify authorization requests for line-of-business, urgency level, type of service, and assess for complete/incomplete record submission.
8. Perform complete, accurate, and consistent data entry into system software applications in accordance with policies, procedures and instruction from UM management.
9. Answer inbound UM phone queue calls timely to assist members and/or providers regarding inquiries involving authorizations, SCFHP program services, and/or benefits.
10. Process written and verbal notifications of authorization determinations to members and/or providers within regulatory processing timeframes.
11. Perform other duties as required or assigned.

REQUIREMENTS – Required (R) Desired (D)

The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

1. High school diploma or GED. (R)
2. Minimum two years of experience in a health care setting in positions requiring interaction with members and/or providers. (R)
3. Knowledge of health plan benefits, process and operations related to commercial, Medi-Cal and/or Medicare programs. (D)
4. Proficient in adapting to changing situations and efficiently alternating focus between telephone and non-telephone tasks to support department operations as dictated by business needs. (R)
5. Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R)
6. Demonstrated ability to consistently meet Key Performance Indicators by participating in and achieving the standards put forth to achieve the standard requirements of the Utilization Management Department (R)
7. Ability to work within an interdisciplinary team structure. (R)
8. Work weekends and company holidays as needed based on business and regulatory requirements. (R)
9. Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word, Excel, and specific UM programs. (R)
10. Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
11. Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers and outside entities over the telephone, in person or in writing. (R)
12. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
13. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
14. Ability to maintain confidentiality. (R)
15. Ability to comply with all SCFHP policies and procedures. (R)
16. Ability to perform the job safely and with respect to others, to property and to individual safety. (R)

WORKING CONDITIONS

Duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.

PHYSICAL REQUIREMENTS

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:

1. Mobility Requirements regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
2. Lifting Requirements regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
3. Visual Requirements ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)
4. Dexterity Requirements regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)
5. Hearing/Talking Requirements ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
6. Reasoning Requirements ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)

ENVIRONMENTAL CONDITIONS

General office conditions. May be exposed to moderate noise levels.