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Role Description

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
• Practitioner outreach calls
• Grievance and appeals
• Triage and case assignments

Key responsibilities include:

• Process documents through UM systems: CareRadius, CareAfiliate, RightFax, and Orion.
• 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.
• Assist with monitoring client escalation mailboxes and responding to requests in a timely manner.
• Conduct or support UM system testing (as needed).
• Self-assign and complete tasks as they appear in assigned buckets in CareRadius and Orion.
• Assist in processing Grievances and Appeals (as needed).
• Other duties as assigned.

Qualifications

• High school diploma/GED required.
• One or more years’ experience in a health care related field, preferably in managed care or utilization review.
• Ability to read, analyze and interpret documents such as company policies, procedures, and operating instructions.
• Ability to write routine correspondence.
• 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.
• Experience using CareRadius, CareAfiliate, RightFax, Orion 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 problem-solving role.
• Ability to work remotely in a dedicated workspace with a door to protect company data and PHI.
• Must have high-speed internet.
• Ability to support team goals and initiatives.
• Must be collaborative with team members while operating in a fast-paced regulatory environment.

Requirements

• This is a part-time role, 20 hours per week, working Monday-Friday 1p to 5p Eastern time.
• The hourly wage for this opportunity is $17.00 to $22.00. Compensation depends on several factors: qualifications, skills, competencies, and experience.

Benefits

• Competitive salary
• Company bonus potential
• Medical, dental, vision
• 401k with match
• Generous paid time off
• Free gym membership to over 13,000 fitness locations in the US
• Other great benefits

Company Description

Tivity Health, Inc. is a leading provider of healthy life-changing solutions, including SilverSneakers®, ForeverFit®, and WholeHealth Living®. We help adults improve their health and support them on life's journey by providing access to in-person and virtual physical activity, social and mental enrichment programs, as well as a full suite of physical medicine and integrative health services. Our suite of services support health plans, employers, health systems, and providers nationwide as they seek to reduce costs and improve health outcomes.