Job Title: UM Coordinator
Department: Health Services - UM

About the role:
We are currently seeking a highly motivated UM Coordinator. This role will report to a Manager - UM and enable us to continue to scale in the healthcare industry.

You are:

• Comfortable with ambiguity and biased towards action

• Relentlessly resourceful

• Growth-oriented

• Mission-driven

What You'll Do:

• Responsible for supporting clinical, management, and client activities, comprising the UM Program.

• Must be proficient in all UM processes such as and understanding of the CCS process, what requires precertification from health plan, Division of Financial Responsibilities, Delegation agreements and Health Plan contracts.

• Ensure we are processing quality referrals in a timely manner meeting the health plan standards.

• Comply with all UM policies and procedures. Annual review of selected UM policies.

• Process Routine, Urgent & Retro treatment authorization requests according to the NMM Policy & Procedure and Health Plan turn-around time standards. NMM will use these timeframes for consistency.

  • Pharmacy requests 24 hrs

  • Urgent 72 hrs- Calendar days

  • Routines 5 days- Business days

• Maintain understanding of business rules and regulatory requirements pertaining to UM processes and operations.

• Accurately review, screen and process daily assigned UM referrals (300-500) in accordance with IPA and health plan TAT guidelines.

• Coordinator will check that all required fields are completed correctly. If missing DX and or CPT a call will be made to the provider while they are screening.

• Coordinators will use level 1 guidelines to release referrals that meet specific business rules. If benefit check required document what specifics are to be checked.

• If referral requires clinical review or are above a Level 1 guideline, the referral is sent to the nurse queue for review. Urgent and or Routine nurse queues.

• Contact the provider office as needed for clarification of ICD 10 or CPT codes and or to request medical records.

• Maintain high level of accuracy when processing referrals. Random audits will be done to verify.

• Responsible for verification to include but not limited to: benefit matrix through DOFR, eligibility, provider status (contracted/non-contracted), CCS, carved out and others.

• Responsible for obtaining authorization approvals from the appropriate physician assigned to that IPA.

• Contact the health plan for pre-certification of surgeries, DME, home health, outpatient services, optometry and outpatient psychiatric service as indicated per the contract.

• If assigned to work the Medical Director queue, the coordinator will process as per the Medical Directors instruction.

• Coordinator will release those that are approved.

• Coordinator will populate the required fields for the denial and or redirection and forward to the denial team to process the request.

• Attend to provider and interdepartmental calls in accordance with exceptional customer service

• Ability to keep high level of confidence and discretion when dealing with sensitive matters relating to providers and members.

• Report any issues to UM Coordinator Level 3- Lead.

• Maintains strictest confidentiality at all times.

• Maintain good relationships with health plans and medical directors and external contacts.

• Team-player, assist others as needed in order to comply with TAT.

• Support departmental initiatives such as policy/procedure review.

• May be required to cover occasional weekend and or holiday to maintain our required TAT.

Minimum Qualifications:

• High School Graduate or equivalent

• A minimum of two years experienced in managed care environment to include but not limited to an IPA or MSO preferred.

• Current knowledge of Managed Care UM procedures

• Knowledge of medical terminology, RVS, CPT, HPCS, ICD-10 codes.

• Proficient with Microsoft applications’ and EZCAP

• Good organizational skills.

• Good verbal and written communication skills.

• Must have the ability to multitask and problem solve in a fast pace work environment.

You're great for this role if:

• Punctuality, precision with details, creativity, etc. would be helpful for this position.

• Ability to follow directions and perform work independently according to department standards.

• Able to function effectively under time constraint.

• Able to maintain confidentiality at all times.

• Willingness to accept responsibility and desire to learn new task.

• Ability to comply and follow company policies and procedures.

• Must be a strong team player, punctual and have excellent attendance record.

Who We Are:

ApolloMed (NASDAQ: AMEH) is a physician-centric, technology-powered healthcare management company. We are building and operating a novel, integrated, value-based healthcare delivery platform to empower our physicians to provide the highest quality of end-to-end care for their patients in a cost-effective manner. Our mission is to combine our clinical experience, best-in-class delivery network, and technological expertise in order to improve patient outcomes, increase access to healthcare, and make the US healthcare system more efficient.

Our platform currently empowers over 10,000 physicians to provide care for over 1.2 million patients nationwide. Our rapid growth and unique position at the intersection of all major healthcare stakeholders (payer, provider, and patient) gives us an unparalleled opportunity to combine clinical and technological expertise in order to improve patient outcomes, increase access to quality healthcare, and reduce the waste in the US healthcare system.

Our Values:

• Patients First

• Empowering the Independent Provider

• Be Innovative

• Operate with Integrity & Deliver Excellence

• Team of One

Environmental Job Requirements and Working Conditions:

• This position is remotely based in the U.S.

• The target pay range for this role is $16.50 - $28.50 per hour. This salary range represents our national target range for this role.

ApolloMed is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@networkmedicalmanagement.com to request an accommodation.

Additional Information:

The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.