UM Retrospective Review Coordinator (Temporary)

Job Number: 1325

Workplace Type:

Position Title: UM/CM Care Coordinator

External Description:

The UM Retrospective Review Coordinator assists and supports the clinical team (UM Retro Nurse/Medical Director) with administrative task related to processing Utilization Management’s retrospective cases received from Claims Department.

 

General Duties/Responsibilities:

(May include but are not limited to)

• Monitor EZ Cap Workflow Folders
• Verify eligibility and/or benefit coverage for requested services.
• Enter post-service requests in system using ICD 10 and CPT coding.
• Verify all necessary documentation has been submitted for post-service request.
• Accurately documents retro process and any pertinent determination factors within the referral system.
• Answer queue calls relating to UM review and pre-service status.
• Recognize work-related problems and contributes to solutions.
• Meet specific deadlines (responds to various workloads by assigning task priorities according to department policies, standards and needs).
• Maintain confidentiality of information between and among health care professionals.
• Other duties as assigned by UM Supervisor.

 

Minimum Requirements:

 

• Minimum Experience:
• Preferred 1-2 years experience in a medical setting working with IPAs, entering referrals/prior authorizations. Must of have knowledge of ICD10, CPT codes, Managed Care Plans, medical terminology (certificate preferred) and referral system (Access Express/Portal/N-coder). 

 

• Education/Licensure:
• High School Diploma or General Education Degree (GED) and/or training: or equivalent combination of education and experience
• No Licensure required 

 

• Other:
• Knowledge of Medicare Managed Care Plans
• Computer Skills:  Word, Excel, Microsoft Outlook
• Experience with the application of UM criteria (i.e., Apollo, CMS National and Local Coverage Determinations, etc.)
• Bilingual (English/Spanish) preferred
• Positive, team player   

Essential Physical Functions:

 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

 

• While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
• The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus. 

 

City: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: UM Retrospective Review Coordinator (Temporary)

Company Profile:

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].