UM Inpatient Service Coordinator - $22/hr

Overview

The UM Inpatient Service Coordinator is a telphonic role working with hospital offices regarding inpatient or hospital stays processing prior authorizations for members. This position is flexible remote working M - F 8:30 am to 5 pm.

About Us

Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Brief Summary Of Purpose

Under the direction of the Supervisor, Inpatient Care Coordinator communicates with contracted and non-contracted facilities/agencies/providers and members to collect pertinent Acute Inpatient, Maternity and Post-Acute authorization request data and disseminates information to the Utilization Nurses for review. Additionally, supports the authorization process by receiving incoming faxed/mailed/emailed/etc. requests and initiates entry of service request shells into core system (TruCare and/or QNXT). Responsible for incoming calls for the UM department addressing and/or referring customer (provider/member) calls/inquiries, provide direction regarding Plan policies, procedures and when applicable, benefit information. Responsible for first level call resolution oversight. Interact with department’s Manager to identify areas that need improvement or change and oversee implementation of change if applicable. Work in conjunction with other FH departments to assist in processing authorization information in order to facilitate the member’s medical services or the providers’ claims. Interprets and triages information to ensure appropriate action is initiated to meet regulatory bodies’ standards and to maintain the quality and timeliness of the authorization process.

Responsibilities

Primary summary of purpose:

• Renaming all incoming faxes including requests for maternity, acute, subacute and discharge planning requests for all Utilization Management requests
• Upload clinical to correct authorization, archive to correct folder
• Handles an appropriately high volume of daily auth entries into the core system. This volume target will be communicated to the staff on a regular basis by the Manager as business needs dictate.
• Assigning auth’s to the UM nurses per the updated UM nurse assignment grid per product delegation
• Enters, researches, investigates and documents all authorizations from receipt to notification in TruCare for all product lines.
• Accepts authorizations for FH members, screens for member eligibility and enters information into the FH Core system.
• Adheres to department standards for completion of referral TAT and notifications.
• Run daily census through Business Objects to work ProAuth, maternity, Acute authorizations within Turn Around Time
• Review hospital discharge notifications, discharging Acute, Elective and Maternity authorizations within parameters of Fallon UM guidelines
• Review post-acute authorization requests, validate eligibility information, create an authorization, and triage to the UM nurse as per product delegation
• Research claims in QNXT to verify admission and discharge dates
• Research member in the ADT admission and discharge system to confirm facility admission, admission and discharge dates
• Communicates with contracted and non-contracted facilities/agencies/providers to collect pertinent data regarding an episode of care and give applicable policy information and/or authorization numbers and status to facility/agency
• Communicate with inter/intra departmental personnel regarding all aspects of the authorization process as requested
• Other duties as determined by Supervisor
  
  

Qualifications

Education:

Assoicate's degree. Some advanced education highly preferred.

License/Certification

N/A

Experience

• 1-3 years’ professional experience in a related position, preferably in health care.
• Experience in a managed care or call center setting or physician’s office; knowledge of managed care and/or utilization management strategies advisable
• High level competency with “customer service” phone skills
• Good writing skills with familiarity and comfort with medical terminology.
• Ability to work independently and make appropriate decisions within the realm of set business and benefit guidelines
• Good interpersonal communication and problem-solving skills.
• Experienced in understanding what is being asked during phone calls while researching for appropriate answers.
• Computer literate, particularly in Windows based applications (Word, Excel, PowerPoint, and Access). 
  
  

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.