Providence

Job Information

St. Joseph Health / Covenant Health Utilization Management Assistant - Ambulatory UM *$1,000 Sign-On Bonus* in Anaheim, California

We are looking for a Utilization Management Assistant (with a $1,000 Sign-On Bonus) for the Ambulatory UM Department at St. Joseph Heritage Healthcare.

$1,000 Sign-On Bonus for eligible external candidates who meet all conditions for payment - this is in addition to the fantastic benefits and compensation package offered by Providence that begin on your first day of employment.

Location: Anaheim, CA

Work Schedule: Full Time - 80 Biweekly Hours

Shift: 8-hour, Days

Job Summary:

Under the direction of the Utilization Supervisor/ Manager, this position is responsible for the distribution, review, accurate and timely processing of SJHH patient referrals requested from providers.

Essential Functions:

  • Responsible for verification of member’s eligibility (reporting to enrollment if not in IDX) and checks benefits of members for services requested per evidence of coverage guidelines.

  • Performs preliminary review and assessment of referrals for completeness: Supporting clinical documentation for the referral request, ICD-10, CPT, or HCPC codes. Assists in gathering clinical information needed to substantiate the medical necessity of the requested referrals.

  • Ability to prioritize work, meet departmental productivity standards and maintain compliance of 95% or greater for Turn -Around-Time processing of referrals per ICE standards. This work includes patient and provider notification of referral outcome.

  • Referrals HMO as well as Non-HMO will be processed according to the established SJHH internal process (electronic submission when applicable) utilizing contracted vendors/providers as determined by the Contracting Department and Leadership with an accuracy rate of 98%.

  • Review and authorize all procedures on the SJHH Internal Pass-Thru and UMA Sign-Off Lists. Complete data entry of referrals in IDX, including those requiring escalation for nurse or physician review.

  • Maintains files and documentation with an accuracy rate of 95% or greater according to UM departmental standards.

  • Communicates with physician offices, processing staff, and other departments as needed to ensure collaboration and open discussion regarding referral process. This includes responding to messages within next business day with a compliance rate of 90% or greater.

  • Identifies and communicates to Lead/Supervisor or Manager any trends/patterns that adversely impact flow, such as offices or vendors not following established process for referral submission.

  • Assists in the denial letter process under the direction of the nurse reviewer, UMA Lead or Supervisor when appropriate. Initiates Information Member Notice based on benefit or eligibility.

Skills:

  • Moderate computer skills including Microsoft Windows, Word, Excel, and an e-mail system required.

  • Accurate typing of 45+ WPM required.

  • Ability to work independently, self-prioritize workload and functions well as part of a team.

  • Ability to communicate both verbally and in writing in a clear and concise manner.

  • Knowledge of insurances and managed care.

  • Demonstrates dependability.

  • Must be able to work under general supervision.

  • Demonstrates willingness to assist others.

  • Must have a professional and mature demeanor.

  • Must be able to work in a fast-paced department and handle multiple tasks, work with interruptions, and deal effectively with confidential information.

  • Proficiency in MS Excel, Access and Word applications, preferred.

  • Bilingual English/Spanish communication skills, preferred.

Minimum Position Requirements:

Experience: 1 year Experience in a hospital, health insurance company or medical office/clinic setting.

Preferred Position Qualifications:

Education:

  • Coursework/Training - College level classes, preferably in healthcare or related field "or"

  • Associate's Degree - Healthcare or related field

Experience: 1 year Experience in utilization management or case management with experience in medical terminology and coding.

Licenses/Certifications: MA Certification

Mission Heritage Medical Group is one of California's most respected medical groups. With over 3,000 employees and 75 locations throughout California, including, Northern California, Orange County, High Desert and Los Angeles County, Mission Heritage Medical Group has been continually recognized as a leader in quality, customer service and information technology. This kind of success is the result of team work, a commitment to excellence and a strong adherence to the organization's mission, vision and values. Mission Heritage Medical Group provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, national origin, age, disability or genetics. In addition to federal law requirements, Mission Heritage Medical Group complies with applicable state and local laws governing nondiscrimination in employment in every location in which the company has facilities. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

Company: Providence Medical Foundation

Category: Quality / Risk / Safety (Non-Clinical)

Req ID: R348626

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