#122648 PHSO UM Referral Coordinator - Per Diem - Hybrid

DESCRIPTION

Under the direction of the Assistant Director, the Population Health Managed Care Per Diem Utilization Referral Coordinator is responsible for processing a high volume of HMO prior authorization requests. They will ensure that the orders / referrals are part of the Health Plan benefit or escalate the referral to the RN Care Management team. The UM Referral Coordinator works in Epic, health plan portals, right fax, and other internal systems to process referrals timely. UM Referral coordinator approves certain inpatient and outpatient authorizations at a coordinator level per UM guidelines and processes carve out/non covered benefit authorizations. UM Referral Coordinator reviews and processes retro claim UM requests for authorization.

The UM Referral Coordinator works closely with the High Risk Case Managers, Social Worker, and Pharmacists as key members of the interdisciplinary care team. Will assist in helping members navigate the complex health system; assist with redirections, help schedule appointments, identify and coordinate resources, educate patients on the provider's treatment plan, promote self-efficacy, and identify & resolve any barriers.

MINIMUM QUALIFICATIONS

• Experience working in a health care setting.

• Previous front and back office Primary Care office experience.

• Previous experience working in the community with health education for vulnerable populations, understanding of social factors that contribute to the need for help with health system navigation for wellness.

• Excellent communication skills both verbally and in writing.

• Knowledge in MS office (Excel, PowerPoint, Outlook, Word, Rightfax, etc.).

• Demonstrated ability to coordinate and research the review of difficult, complex Utilization Management issues.

PREFERRED QUALIFICATIONS

• Highly desired experience within HMO or IPA/MSO utilization management /prior authorization department; high volume.
• Good knowledge of HMO benefits/policies for authorization; Understanding of Division of Financial Responsibility (DOFR.
• Strong understanding of Medicare, Commercial health plan benefits.
• Experience with processing retro claims/UM authorizations.
• Electronic Medical Record/ Epic experience.
• Experience working in a remote environment.
• Experience working on a multidisciplinary team.

SPECIAL CONDITIONS

• Must be able to work various hours and locations based on business needs.
• Employment is subject to a criminal background check and pre-employment physical.
• Holiday and weekend availability required.
• Employee required to have consistent high-speed internet and appropriate workstation when working remotely.

Job offer is contingent on successful engagement in the UC COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

If applicable, life-support certifications (BLS, NRP, ACLS, etc.) must include hands-on practice and in-person skills assessment; online-only certification is not acceptable.

UC San Diego Health is the only academic health system in the San Diego region, providing leading-edge care in patient care, biomedical research, education, and community service. Our facilities include two university hospitals, a National Cancer Institute-designated Comprehensive Cancer Center, Shiley Eye Institute, Sulpizio Cardiovascular Center, the only Burn Center in the county, and and dozens of outpatient clinics. We invite you to join our team!

Applications/Resumes are accepted for current job openings only. For full consideration on any job, applications must be received prior to the initial closing date. If a job has an extended deadline, applications/resumes will be considered during the extension period; however, a job may be filled before the extended date is reached.

To foster the best possible working and learning environment, UC San Diego strives to cultivate a rich and diverse environment, inclusive and supportive of all students, faculty, staff and visitors. For more information, please visit UC San Diego Principles of Community.

UC San Diego 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. For the complete University of California nondiscrimination and affirmative action policy see: http://www-hr.ucsd.edu/saa/nondiscr.html

UC San Diego is a smoke and tobacco free environment. Please visit smokefree.ucsd.edu for more information.

UC San Diego Health maintains a marijuana and drug free environment. Employees may be subject to drug screening.