UM Coordinator

About The Role

The UM Coordinator is responsible for coordinating all aspects of the prior authorization process, including member eligibility and benefit verification, gathering necessary clinical information from electronic medical record, and timely communication with members, providers and facility staff. Candidates should possess knowledge of third-party reimbursement regulations and medical terminology. Success in this role will require strong interpersonal communication, critical thinking, and problem-solving skills. The successful candidate will interact and communicate effectively with internal and external customers, providers in clinical settings, and all members of the organization.

Primary Responsibilities

Research and confirm authorization requirements and communicate to member, providers, and facility staff.

Collect data upon notification from patient / patient representative, physician, or hospital; verify member eligibility, plan participation and provider participation status.

Create cases within documentation system in accordance with departmental workflows, policies, and procedures.

Identify and correctly attach clinical documentation to appropriate cases within the documentation system.

Interact telephonically with members, providers, and facilities to determine requests for type of care, including inbound and outbound calls as needed.

Maintain accurate documentation within the clinical record according to workflows, policies and procedures.

Collaborate with the clinical team to address provider or member questions, issues, or concerns.

Play an active role in continuous improvement activities and quality initiatives to support positive outcomes for members, providers, and clients.

Maintain professional communication with all internal and external stakeholders.

Essential Qualifications

HS diploma or GED is required.

Strong skills in medical record review.

Knowledge of CPT codes, preferred.

Prior knowledge of JIVA, preferred.

Excellent customer service and communication skills.

Strong attention to detail and accuracy.

Ability to define problems, obtain data, and establish facts.

Ability to work proficiently on a computer (PC) with working knowledge of Microsoft Word and Excel.

Excellent data entry skills.

Bachelor’s degree preferred, but not required.

Familiarity with medical terminology required.

Familiarity with third party payor processes and procedures strongly desired.

About

At Brighton Health Plan Solutions, LLC, our people are committed to the improvement of how healthcare is accessed and delivered. When you join our team, you’ll become part of a diverse and welcoming culture focused on encouragement, respect and increasing diversity, inclusion, and a sense of belonging at every level. Here, you’ll be encouraged to bring your authentic self to work with all your unique abilities.

Brighton Health Plan Solutions partners with self-insured employers, Taft-Hartley Trusts, health systems, providers as well as other TPAs, and enables them to solve the problems facing today’s healthcare with our flexible and cutting-edge third-party administration services. Our unique perspective stems from decades of health plan management expertise, our proprietary provider networks, and innovative technology platform. As a healthcare enablement company, we unlock opportunities that provide clients with the customizable tools they need to enhance the member experience, improve health outcomes, and achieve their healthcare goals and objectives. Together with our trusted partners, we are transforming the health plan experience with the promise of turning today’s challenges into tomorrow’s solutions. Come be a part of the Brightest Ideas in Healthcare™.

Company Mission

Transform the health plan experience – how health care is accessed and delivered – by bringing outstanding products and services to our partners.

Company Vision

Redefine health care quality and value by aligning the incentives of our partners in powerful and unique ways.

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