Under the direction of the Assistant Director, the Population Health Managed Care Per Diem Utilization Referral Coordinator is responsible for processing a high volume of HMO prior authorization requests. They will ensure that the orders / referrals are part of the Health Plan benefit or escalate the referral to the RN Care Management team. The UM Referral Coordinator works in Epic, health plan portals, right fax, and other internal systems to process referrals timely. UM Referral coordinator approves certain inpatient and outpatient authorizations at a coordinator level per UM guidelines and processes carve out/non covered benefit authorizations. UM Referral Coordinator reviews and processes retro claim UM requests for authorization.

The UM Referral Coordinator works closely with the High Risk Case Managers, Social Worker, and Pharmacists as key members of the interdisciplinary care team. Will assist in helping members navigate the complex health system; assist with redirections, help schedule appointments, identify and coordinate resources, educate patients on the provider's treatment plan, promote self-efficacy, and identify & resolve any barriers.

• Experience working in a health care setting.

• Previous front and back office Primary Care office experience.

• Previous experience working in the community with health education for vulnerable populations, understanding of social factors that contribute to the need for help with health system navigation for wellness.

• Excellent communication skills both verbally and in writing.

• Knowledge in MS office (Excel, PowerPoint, Outlook, Word, Rightfax, etc.).

• Demonstrated ability to coordinate and research the review of difficult, complex Utilization Management issues.

• Highly desired experience within HMO or IPA/MSO utilization management /prior authorization department; high volume.
• Good knowledge of HMO benefits/policies for authorization; Understanding of Division of Financial Responsibility (DOFR.
• Strong understanding of Medicare, Commercial health plan benefits.
• Experience with processing retro claims/UM authorizations.
• Electronic Medical Record/ Epic experience.
• Experience working in a remote environment.
• Experience working on a multidisciplinary team.

• Must be able to work various hours and locations based on business needs.
• Employment is subject to a criminal background check and pre-employment physical.
• Holiday and weekend availability required.
• Employee required to have consistent high-speed internet and appropriate workstation when working remotely.