The Utilization Management Coordinator is responsible for supporting clinical, management, and client activities, comprising the UM Program. The Utilization Management Coordinator must be proficient in all UM processes such as pre-authorizations, claim reviews, triage and case assignments.
• Process documents through UM systems; Alchemy, RightFax, and Workflow
• Track initial/concurrent service authorizations, denials, authorization gaps, and appeals status
• Manage and process case assignments for Clinical Peer Reviewers and Clinical Staff
• Process practitioner pre-authorization requests while adhering to administrative guidelines, policies and procedures
• Monitor turnaround time of tasks to meet regulatory requirements as well as specific state and federal requirements
• Maintain a high level of accuracy when processing letters in coordination with clinical peer reviewers. Coordinate letter QA with clinical peer reviewers to meet turnaround time requirements
• Maintain understanding of business rules and regulatory requirements pertaining to UM processes and operations
• Support departmental initiatives such as policy/procedure review, audit preparation, and work instruction updates
• Process incoming mail
• Conduct or support UM system testing (as needed)
• Self-assign and complete tasks as they appear in the UM Admin Bucket
• Assist in processing Grievances and Appeals (as needed)
• Others duties as assigned
High school diploma/GED required
One or more years’ experience in a health care related field, preferably in managed care or utilization review.
Knowledge / Skills Language Skills:
Ability to read, analyze and interpret documents such as company policies, procedures, and operating instructions; ability to write routine correspondences.
Ability to solve practical problems and deal with variables. Ability to interpret various instructions furnished in written, oral, schedule, or electronic form. Ability to prioritize to meet deadlines and required turnaround times.
Ability to use computer software, including email, word processing and spreadsheets. Ability to use common office equipment, e.g., fax, copy machine, printer, scanner etc. Experience using Alchemy, RightFax and Workflow is a plus.
Must exhibit strong interpersonal skills and professionalism. Strong verbal, telephonic and written communication skills are required. Ability to work under pressure; must have strong listening skills. Ability to build relationships with internal/external customers. Ability to work with practitioners and office managers in an educational and in a problem-solving role. Ability to work with offsite physician and clinical leadership (medical directors, clinical reviewers and committee members).
Team Skills: Ability to support team goals and initiatives. Must be collaborative with team members while operating in a fast-paced regulatory environment.
About Tivity Health
Tivity Health is a leading provider of fitness and health improvement programs, with strong capabilities in developing and managing network solutions. Through our existing three networks (SilverSneakers® - the nation’s leading fitness program for older adults, Prime® - membership access to the nation’s largest network of fitness centers, and WholeHealth Living – specialty medical network development and benefits management), Tivity Health is focused on targeted population health for those 50 and over.
Tivity Health is an equal employment opportunity employer and is committed to a proactive program of diversity development. Tivity Health will continue to recruit, hire, train, and promote into all job levels without regard to race, religion, gender, marital status, familial status, national origin, age, mental or physical disability, sexual orientation, gender identity, source of income, or veteran status.