At Quantum Recruiters we focus intently on providing talent to leading employers throughout the Pacific Northwest. For over 80 years, our client has built a reputation based on taking great care of people by delivering insurance plans to individuals and businesses. We are currently recruiting to fill two (2) full time, Utilization Management Coordinator positions.

This is a contract, hybrid opportunity lasting approximately 3 months!

Essential Responsibilities:

• High level - Adhere to dependability, member and provider focus, and all performance criteria as established by the department including: timeliness, production, and quality standards for all functions.
• Follow stringent guidelines to ensure all work meets corporate standards for accuracy and compliance with federal, state, and national accreditation regulations.
• UM Process - Coordinate, create, and document UM cases in the electronic record by validating preauthorization requirements, utilizing a basic understanding of ICD, CPT and HCPCS codes, and including plan types, member benefits, eligibility, limitations, exclusions, and claims history.
• Assess accuracy of daily inpatient information from external systems and inpatient facilities, compile inpatient data, create inpatient events including diagnosis codes, and triage for review by UM and CM clinical staff.
• Collaborate with clinical staff by synchronizing information for utilization management, care management, prior authorization, inpatient stay, and retroactive claim reviews. Integrate medical records as required and document status of internal or external reviews in the medical record. Identify and promptly initiate corrective steps to resolve workflow issues.
• Administratively authorize services as directed by UM Leadership.
• Effectively manage an active telephonic queue by delivering excellent customer service to incoming caller and documenting HIPAA compliance. Provide information on prior authorization, referrals, inpatient admissions and stays, health-related information, determinations, claims review, and possess an understanding of when to forward members and providers to Appeals and Grievances. Manage difficult calls and escalate or triage calls to more experienced staff as necessary.
• Work between multiple systems, utilizing critical thinking and problem-solving skills while successfully keeping the member at the center.
• Identify and keep readily accessible all up-to-date reference documents, policies and procedures needed to be successful.
• People - Attend and contribute to cross-functional member-focused meetings, educate team members on UM functions, and assist members in getting the right care at the right time.
• Utilize knowledge, understanding and critical thinking to research difficult cases related to UM processes and requirements from members, providers, employer groups, agents, member representatives and internal customers.
• Serve as a liaison between members and providers regarding benefit utilization and requirements. Provide education and facilitate the member and provider understanding and experience of utilization processes, including benefit structure, contract parameters, and of the information necessary to effectively complete a prior authorization or inpatient stay.

Supporting Responsibilities:

• Meet department and company performance and attendance expectations.
• Follow the privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: Minimum of two years of experience in the health insurance industry or medical setting required. One year experience working with CPT/HCPCS/ICD coding preferred. Other equivalent professional related experience may be considered.

Education, Certificates, Licenses: High school diploma or equivalent required, associate degree, medical assistant certification, licensed professional nurse or certified professional coding certification preferred.

Knowledge: Demonstrated basic knowledge and understanding of medical terminology, procedures, anatomy, diagnoses, care modalities, treatment plans, and medical coding. Basic understanding of insurance, and standard medical billing practices preferred. Proficient computer, and strong written and verbal communication skills. Strong organizational skills and experience with Microsoft Office programs, medical, and claims management software. The ability to work independently at times with minimal supervision.

Please submit a resume for immediate consideration!