This position is available fully remote in Washington State.

Job Summary

Responsible for administrative functions in processing Utilization Management (UM) organization determinations for services requiring authorization and hospital notification. Utilizes knowledge of Medicare and Medicaid guidelines in order to facilitate and comply with the UM processes in data entry of authorization requests, eligibility verification, benefit determinations, timely letter fulfilment, and support to UM clinical staff.

Essential Functions (all levels)

• Performs data entry for all referral, prior authorizations and hospital notifications; attaches and/or includes clinical documents as needed.
• Utilizes knowledge to determine appropriate CPT, HCPC, ICD-10 codes using CMS, NCQA and HCA criteria.
• Researches and validates benefit and prior authorization requirements to determine appropriate course of action within the Care Management system.
• Reviews, corrects, and approves authorization requests via the web portal; determines appropriate level of complexity and refers cases requiring clinical review to a nurse reviewer.
• Accurately applies policies & procedures, benefit and eligibility standards to all incoming requests.
• Conducts research, validates data, and responds to complex inquiries from multiple sources, including but not limited to members, nurses, medical providers, customer service, operations, appeals, case management and care coordination.
• Gathers information and provides accurate and timely correspondence to members and providers.]
• Reviews completed denial letters for accuracy and adherence to compliance deadlines. Edits and proofreads content for appropriate medical terminology and MCG criteria. Ensures letters are mailed within established timeframes.
  • Responds to telephone and written inquiries from providers and in-house departments.
  • Escalates issues to Supervisor, Intake UM as needed.
• Reporting to work on time and for all scheduled shifts is essential to this position.
• Other duties as assigned. Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion.

Essential Functions (Utilization Management Coordinator II)

• Perform all functions of a Utilization Management Coordinator I
• Exceed minimum production average of 30 authorizations entered a day for a minimum of four consecutive months
• Exceed quality goal with over 90% accuracy on internal audits for a minimum of four consecutive months
• Able to accurately enter both behavioral health and physical health authorizations
• Writes and sends physician denial letters following documented process
• Addresses issues escalated from Customer Service, review and update authorizations as applicable and provides education to support customer service via QRT process
• Reviews and addresses system errors in the medical management system via the Search Errors Report

Essential Functions (Senior Utilization Management Coordinator)

• Perform all functions of a Utilization Management Coordinator II
• Exceed minimum production average of 50 authorizations entered a day for a minimum of six consecutive months
• Exceed quality goal with over 95% accuracy on internal audits for a minimum of six consecutive months
• Completes the jail transitions report, discharge lists, transitions of care worklist and post discharge calls report
• Outreaches to members on the phone to assist with making appointments or transportation arrangements

Qualifications

Education

• Associates degree or an equivalent combination of education and highly relevant experience required

Experience

• Preferred one year customer service experience
• Experience in a Healthcare setting preferred
• Experience in Managed Care preferred

Employment Eligibility

• Complete and successfully pass a criminal background check
• Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency

Knowledge, Skills, and Abilities

• Knowledge of medical terminology and healthcare process preferred
• Knowledge of Washington Apple Health and Medicare Advantage Plans preferred
• Strong analytical skills and the ability to interpret, evaluate and formulate action plans based upon data
• Experience in care management workflow systems
• Effective verbal and written communication skills
• Flexibility and willingness to work in a matrix-management environment
• Demonstrated organizational, time management, and project management skills
• Ability to handle multiple priorities in a fast-paced environment
  • Ability to multi-task and deal with complex assignments on a frequent basis
• Demonstrated proficiency and experience with Microsoft Office products
• Strong written and verbal communication skills; able to communicate with and collaborate effectively with physicians and allied health care providers
• Ability to work independently
• Willingness to be part of a fast moving, and dynamic team
  • Collaborate with others in a respectful manner
• Perform all functions of the job with accuracy, attention to detail and within established timeframes.
  • Meet attendance and punctuality standards
• Demonstrate professional courtesy to others and ability to maintain confidentiality

CHPW OFFERS ROBUST TOTAL REWARDS

The position is FLSA Non-Exempt (hourly) and is eligible for overtime. The position is also eligible for as an annual incentive based on company, department, and individual performance goals. Full and Part - time employees have the option to enroll in medical, dental, vision and voluntary life insurance benefits, and 401(k) retirement benefits effective the 1st of the month following or coinciding with their start date. CHPW provides a 6% 401(k) employer match, Basic Life, Accidental Death and Dismemberment insurance, short and long-term disability, financial coaching, and wellness programs at no cost.

CHPW employees start earning 17 days of Paid Time Off (PTO) and receive 40 hours of community service for volunteer time, and two floating holidays immediately. The company offers 10 standard holidays, paid jury duty and compassion time.

CHPW offers a monthly stipend to offset work-from-home expenses for roles that are 100% remote.

Due to business needs, there are some hourly roles required to work during non-standard work hours and or weekends on a rotational basis and/or to meet contractual obligations for extended periods of time. A non-standard shift may include shifts that regularly start after 10am and/or may include weekend shifts. Employees working a non-standard shift may receive an additional hourly premium.

SENSORY/PHYSICAL/MENTAL REQUIREMENTS

Sensory*:

• Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

Physical*:

• Extended periods of sitting, computer use, talking and possibly standing
• Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion
• Frequent torso/back static position; occasional stooping, bending and twisting
• Some kneeling, pushing, pulling, lifting and carrying (not over 25 pounds), twisting and reaching

Mental:

• Must have the ability to learn and prioritize multiple tasks within the scope and guidelines of the position and its applicable licensure requirements, many requiring extremely complex cognitive capabilities. Must be able to manage conflict, communicate effectively and meet time-sensitive deadlines.

WORK ENVIRONMENT

Office environment with frequent environmental exposure to low-grade radiation from computer monitors; fast paced with frequent interruptions.

PROTECTED HEALTH INFORMATION (PHI) ACCESS

All information (written, verbal, electronic, etc.) that an employee encounters while working at CHPW is considered confidential. CHPW employees may encounter protected health information in the regular course of their work at and for CHPW. This position may be exposed to and required to deal with highly confidential and sensitive material and must adhere to CHPW policies, guidelines, and all applicable laws and regulations at all times.

• Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.

This job description is intended to describe the general content and the requirements for satisfactory performance in this position. It is not to be construed as an exhaustive statement of the duties, responsibilities or requirements of this position.

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)