Utilization Management Coordinator

Department: Care Preferred - Case Management
Reports To: Chief of Care Coordination

Position Overview:

This position serves as the Utilization Management Coordinator for Partners Health Plan’s Medicaid only line of business. The Utilization Management Coordinator works directly with PHP Case Manager(s); CCOs/HHs, and other related entities to review assessments, clinicals, and any other needed information to determine medical necessity for the authorization of necessary services.

Duties and Responsibilities:

  • With input from Case Manager (s), the Chief Medical Officer, CCOs/HHs, evaluate requests for services for duration and scope (such as PCA Level 1 and 2, PERS, DME) against standard criteria.
  • Renders care determinations within specified compliance timeframes, adhering to all regulatory requirements.
  • Contacts service providers/requestors as needed in order to expedite authorizations and approvals.
  • Enters authorizations in electronic health record system. Creates and distributes authorization and denial notices to appropriate providers; ICDNs to member.
  • Communicates with Health Smart’s Utilization Management Department on authorization for other services (such as hospitalizations and skilled nursing facility/rehab stays, etc.).
  • Provide back up to Case Manager as needed.
  • Travel to off-site locations and adhere to PHP’s travel policy, as necessary.
  • All other duties as assigned.

Qualifications:

  • License and registration as an RN or LPN to practice in the state of New York required.
  • Associate degree in Nursing required with a Bachelor’s Degree preferred.
  • 3-5 years’ experience in Utilization Management within a managed care or other health insurance setting required.
  • Experience working with electronic health record systems required.
  • Excellent computer skills with Microsoft Word and Excel required.
  • Minimum of two (2) years’ experience in the field of human services required with developmental disabilities experience preferred.
  • Excellent interpersonal, organizational, verbal and written communication skills along with excellent customer service, follow-up, and an attention to detail also required.

Requirements of All Positions:

  • All employees shall meet PHP’s Compliance and Privacy Regulations, and attend at a minimum of one (1) hour of Compliance and Privacy educational training annually;
  • All employees shall master PHP’s Model of Care and complete all training requirements within the first thirty (30) days of employment and annually thereafter, or as required by state and federal regulations;
  • All employees are required to maintain confidentiality, protect privacy, comply with Protected Health Information regulations, and report violations;
  • Perform functions as they relate to “Improving Health Care Quality” as defined in the National Association of Insurance Commissioners Supplemental Health Care Exhibit that:
    1. Improve health outcomes;
    2. Prevent hospital readmission;
    3. Improve patient safety and reduce medical errors, and
    4. Provide wellness and health promotion activities.

Physical Demands and Work Environment:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this position, the employee is regularly required to talk or hear. The employee frequently is required to use hands or fingers, handle or feel utilize objects, tools or controls. The employee is occasionally required to stand; walk; sit; reach with hands and arms; climb or balance; and stoop, kneel, crouch or crawl.

The employee must occasionally lift and/or move up to 25 pounds, and infrequently up to 50 pounds. Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision, and the ability to adjust focus. The noise level in the work environment is usually moderate.

Equal Opportunity Employer