Utilization Management Coordinator - Duly Health and Care
Downers Grove, IL 60515
About the Job
Good enough isn’t for us. Duly Health and Care’s team members show up every day driven to exceed expectations. We see and support the remarkable in every person within and beyond the walls of our work.
Duly Health and Care works to understand what matters most to you. We recruit and retain team members who share a relentless passion and pride for helping others live happier and healthier lives. We invest in helping our team members develop their talents in a way that is rich in personal meaning. We invite you to join us, fulfill your purpose and make your mark!
Holistic benefits designed to help our team members flourish in all aspects of their lives, including:
- Comprehensive medical and prescription drug benefits that include medical coverage at 100% (after deductible) when utilizing a Duly provider.
- $5,250 Tuition Reimbursement per year.
- 40 hours paid volunteer time off.
- A culture committed to Diversity, Equity, and Inclusion (DEI) and Social Impact
- 12 Weeks parental leave at 100% pay and a financial benefit for adoption and surrogacy for non-physician team members.
- 401(k) Match
- Profit-sharing program
Are you ready to challenge the expected to deliver the extraordinary?
The Utilization Management Specialist is responsible for processing referrals and benefit determinations for capitated health plans. The UM Specialist works in collaboration with the Clinical Services Team, Manager, Medical Director and Providers to ensure that referrals are completed in accordance with Boncura Policies and Procedures.
Responsibilities:The Journeys and Adventures that Await:
- Process referrals in accordance to Boncura Policy /Procedures and health plan requirements. This includes checking eligibility, verifying benefits, verifying medical necessity, and knowledge of referral networks.
- Contacts health plans for referrals/ pre-certifications that require health plan approval.
- Applies MCG guidelines, Medical Group Guidelines and CMS coverage determinations to referral requests as appropriate.
- Ensures referrals are approved within network as medically appropriate.
- Reviews referrals not meeting medical group criteria with the Medical Directors as needed.
- Initiates the processing of denials in accordance with health plan and regulatory requirements under the direction of the Manager, Care Management and Medical Director.
- Interacts in a professional manner with providers, patients, physicians, and staff by demonstrating respect not limited to communications via telephone, E-mail, My Chart or Staff Message.
- Act as a resource for the Clinical Services Department, physicians, providers, patients and work colleagues.
- Assist with submission of health plan reporting to ensure health plan compliance.
- Ability to utilize resources and problem solving skills to achieve resolution when addressing questions/issues from patients, providers, and staff.
- Maintain confidentiality in compliance with HIPPA
- Ability to identify and report problems that need to be escalated to the Utilization Management Supervisor/Manager
- Demonstrates a positive attitude and has the ability to adapt with change.
- Performs other responsibilities and duties as assigned.
The Experiences You Bring:
KNOWLEDGE SKILLS AND ABILITIES:
- Proficient with Medical Terminology
- Proficient in Microsoft Office
- Prior EPIC EHR experience a plus
- Data Entry sills of 30+ wpm required
- Ability to prioritize work responsibilities
EDUCATION and / or CERTIFICATION/LICENSURE:
- Associate Degree Preferred
- Medical Terminology, Coding Experience Desired
EXPERIENCE:
- 2+ years of experience in utilization management in the health plan or medical group environment
- Experience Applying MCG Guidelines (Formerly Milliman Care Guidelines)
- Capitated Referral Experience
- Medical Assistant or Health Plan Experience Preferred