Utilization Review Coordinator jobs in Fullerton, CA

POSITION SUMMARY:

This position works under the direction of the VP, Medical Management in support of ensuring reporting and compliance with the Utilization Management and Quality Management Plans and Work Plans.

EDUCATION/SKILLS/EXPERIENCE REQUIREMENTS:

• Minimum Medical Assistant level education and/or 5 years experience in Utilization Management.
• Strong knowledge of Managed Care principles.
• Knowledge of UM requirements to include turnaround times on all lines of business, UM processes and the ability to evaluate status of compliance with requirements and implement corrective action where necessary.
• General ICD-10 & CPT Coding experience.
• Strong in Microsoft Word & Excel.
• Detail oriented and statistical minded.
• Ability to prioritize and adjust work volume to meet deadlines
• Values and works well in a team environment

DUTIES/RESPONSIBILITIES:

• Oversees Health Plan UM/CM Reporting.
• Works in conjunction and collaborate with other reporting specialists to ensure timely submissions via FTP sites and other platforms.
• Preparation, review, and submission of UM reporting for IPA and Health Plans.
• Utilizes departmental reference tools to ensure submissions are timely, appropriate naming conventions are used and reporting formats/formulas are followed.
• Collaborate with team members to update departmental reference tools.
• Analyzes data for trending, opportunities for improvement, compliance concerns and corrective action plan evaluations.
• Facilitates appropriate work groups for problem solving and interdepartmental solutions when needed.
• Support in Health Plan Audits & Corrective Action implementation.
• Attendance at UM/QM Meetings, when necessary.
• Assists with review and testing of system changes to streamline reporting needs.
• Maintain compliance with HIPAA rules and regulations.
• Promotes professionalism of all employees, including phone etiquette, manners, appearance, and attitude
• Maintains availability and willingness to work adjusted schedules to meet reporting and business needs.
• Maintains availability and willingness to travel if necessary or desirable to meet business needs.
• Other duties, as assigned.

WORK ENVIRONMENT, PHYSICAL DEMANDS AND MENTAL DEMANDS:

1. Typical office environment with no unusual hazards.

2. Repetitive movements with use of keyboard, mouse, and phone.

3. Constant sitting while using the computer terminal.

4. Constant use of sight abilities while reviewing documents.

5. Regularly speak and listen in person, telephone, and remote meetings

6. Constant mental alertness must possess planning/organizing skills and must be able to work under deadlines.

7. Occasionally required to stand, walk, stoop, kneel, bend, crouch and lift up to but not more than 10 pounds.

If you are passionate about providing quality healthcare services and possess the necessary skills and experience, we encourage you to apply for this rewarding position. Join our team today!

This employer participates in E-Verify and will provide the federal government with your Form I-9 information to confirm that you are authorized to work in the U.S.

Job Type: Full-time

Pay: $66,560.00 - $68,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Healthcare setting:

• Long term care

Schedule:

• Day shift
• Monday to Friday

Ability to Relocate:

• Cypress, CA 90630: Relocate before starting work (Required)

Work Location: In person