Utilization Management Care Coordinator

Location: Miami, Fl (Onsite)

About Us:

At Solis Health Plans, we are not just another Medicare Advantage company; we are a community of passionate professionals dedicated to enhancing the well-being of the communities we serve. Our locally rooted organization prioritizes understanding and meeting the unique needs of our members. With a vast network of healthcare professionals and a dedicated Member Services team, we are proud to offer the "Solis Difference," a commitment to quality, efficiency, and collaboration in healthcare.

Position Summary:

The UM Care Coordinators are instrumental in helping patients receive great care with the attention and follow-up they need for optimal healthcare experiences. This requires a flexible attitude, quick thinking and a caring disposition. Duties may vary from day-to-day and week-to-week, but can involve the following tasks and responsibilities:

Key Responsibilities:

• Scheduling UM Authorization and Determination tasks
• Refers all services requiring prior authorization to UM Nurse or BH UM Nurse as appropriate Manage determination placement
• Communicate with nurses and physicians
• Receives and responds to telephonic inquiries from providers regarding status of authorization requests and other questions or concerns
• Guides practitioners to appropriate referral resources
• Handle inbound calls and answer member and provider questions
• Connect with new members via phone and email as requested
• Communicate with members to determine and confirm their needs
• Arrange and coordinate special equipment or therapy for at-home care
• Maintain files and company information as required
• Provide timely data entry referrals for continuing care as necessary
• Perform benefit approvals on services, procedures, and tests that are listed on the UM Coordinator's approval list. (These services do not require clinical judgment nor are reviewed for medical necessity. This list is reviewed as needed and at least annually for continued use by the UM Coordinator)
• Process routine referral services that do not require a Prior Authorization
• Ensures timely printing and mailing of pre-certification, authorization and denial letters
• Appropriately documents interactions and activities into the UM electronic system
• Produces reports from UM electronic system for review and analysis by appropriate Leadership team member
• Assist the company care team with goal setting
• Ensures compliance with all federal, state, and local regulations.
• Help with member data collection including medical records, HRA, etc.
• Maintain patient confidentiality
• Related duties as needed

Qualifications:

• Post High School graduate courses or equivalent with significant experience in healthcare related customer service position; or equivalent combination of education and experience
• Insurance experience in the Medicare and managed care field is preferred
• Knowledge of CMS guidelines and InterQual is preferred
• Excellent computer knowledge is required, including proficient knowledge of Microsoft Office
• Strong decision-making and organizational skills
• Excellent listening, interpersonal, verbal and written communication skills with individuals at all levels of the organization
• Must be able to work with little or no supervision
• Willingness and ability to function independently and as a team member
• Working Knowledge of medical terminology
• Ability to handle multiple functions and prioritize appropriately
• Ability to meet strict deadlines
• Must be patient in dealing with an elderly population and sympathetic to hearing or vision deficiencies
• Ability to read, analyze, and interpret technical procedures or governmental regulations
• Ability to define problems, collect data, establish facts, and draw valid conclusions
• Strong decision-making, analytical skills
• Must be self-motivated, organized and have excellent prioritization skills
• Must be able to work well under stressful conditions
• Must be able to work in fast paced environment

What Sets Us Apart:

Join Solis Health Plans as a Utilization Management Coordinator and become a catalyst for positive change in the lives of our members. At Solis, you will be part of a locally rooted organization deeply committed to understanding and serving our communities. If you are eager to embark on a purpose-driven career that promises growth and the chance to make a significant impact, we encourage you to explore the opportunities available at Solis Health Plans. Join us and be the difference!