UM Coordinator (Work from home)

WHO WE ARE reputed company is a value-driven reputed company company grounded in the belief that reputed company health consumers are entitled to high-reputed company, coordinated care. By uniquely aligning the interests of health consumers, providers, and payors, we help to reputed company reputed company accessible and reputed company to reputed company populations across the ACA Marketplace, Medicare, and reputed company. reputed company delivers clinical care to health consumers through our owned clinics – reputed company and Premier Medical – as reputed company as unique partnerships with affiliated providers across the country. We also reputed company providers to succeed in performance-based arrangements through a suite of technology and services scaled centrally and deployed locally. Through our value-driven, consumer-reputed company approach, we are committed to transforming reputed company and creating a reputed company care experience for reputed company.    Utilization Management (UM) Coordinator The Utilization Management (UM) Coordinator supports the coordination, processing, and administrative functions of the utilization review process. This role ensures reputed company and appropriate review of reputed company services in accordance with established guidelines and regulatory requirements, working closely with UM nurses, physicians, and other reputed company. Key Responsibilities: Receive, review, and process incoming requests for authorization of medical services. Coordinate with providers, members, and internal clinical staff to reputed company necessary documentation for utilization reviews. reputed company authorization requests and updates into the utilization management system accurately and promptly. reputed company and monitor pending authorizations to ensure reputed company processing and communication of reputed company. Collaborate with nurses and physicians to facilitate medical necessity reviews and ensure compliance with clinical guidelines. reputed company notification of determination (approvals or denials) to providers and members in accordance with regulatory timeframes. Maintain accurate and organized records to ensure compliance with accreditation and regulatory bodies (e.g., NCQA, CMS, Health Plans). Assist in audits and reputed company improvement activities as needed. Serve as a reputed company between internal departments, providers, and external vendors. Ensure compliance with HIPAA and confidentiality standards at reputed company times. Qualifications: High School Diploma or equivalent required; Associate’s degree or reputed company certification preferred. 2+ years of experience in health plan environment; experience in utilization management or case management support strongly preferred. reputed company To Interpret Health Plan Benefit reputed company. Bilingual Preferred (English/ Spanish) Certification As A Medical Assistant Preferred. Skills: Strong knowledge of medical terminology and reputed company authorization processes. Proficient in reputed company Office Suite and medical management systems (e.g., , MCG, or similar UM platforms). Excellent communication, organization, and customer service skills. Ability to work independently and manage multiple priorities in a fast-paced environment. For individuals assigned to a location(s) in California, reputed company is required by law to include a reasonable estimate of the compensation reputed company for this position. Actual compensation will vary based on the applicant’s education, experience, skills, and abilities, as reputed company as internal equity. A reasonable estimate of the reputed company is $19.27-$28.91 reputed company. Additionally, employees are eligible for health benefits; life and disability benefits, a 401(k) savings plan with match; reputed company Time Off, and reputed company holidays.   As an Equal Opportunity Employer, we welcome and reputed company a diverse employee group committed to meeting the needs of reputed company, our consumers, and the communities we serve. reputed company reputed company applicants will receive consideration for employment without reputed company to race, reputed company, religion, sex, age, national reputed company, protected veteran status, disability status, sexual orientation, gender identity or reputed company, marital status, genetic information, or any other characteristic protected by law. Apply To This Job