Two years’ experience working in a managed healthcare environment, preferably in the area of UM, QA or auditing.
Bachelor’s degree preferred or equivalent experience
445 Grant Avenue, San Francisco, CA 94108
The Utilization Management (UM) Senior Project & Data Specialist is responsible for providing high-level operational assistance to the Medical Management Department. Serving as the liaison between the UM Department and contracted medical groups and health plans, this position is responsible for coordinating the timely preparation and submission of reports and for preparing and coordinating documentation for health plan and regulatory audits. Monitors regulatory compliance of key UM and Provider Dispute Resolution (PDR) processes by conducting audits. Recommends new processes and procedures designed to improve efficiency or compliance. The UM Senior Project & Data Specialist must be extremely organized with outstanding attention to detail and be able to read and write English with excellent spelling and grammar.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Provide complex administrative support to the UM and PDR department, including project coordination and report preparation, ensuring deadlines are met.
- Serve as liaison between the Medical Management Department and health plans and medical groups by preparing documents and coordinating and organizing the collection of documents for annual and intermittent UM and PDR audits and handling other special projects as requested:
- Gather and review policies and procedures and other information requested by auditors.
- Pull and search from the electronic file all denials and service authorization requests required by auditors.
- Assure that all SAFs or denials are in compliance with the audit requirements.
- Make sure all clinical information is attached and reviewer signatures are printed in the service authorization requests
- Assuring the correct template, language disclosure and accurate denial reason have been applied
- Responsible for notifying UM Director of any timeliness issues with other health plans or medical groups’ authorizations.
- Responsible for notifying Claims department of any delays in receiving authorization reports from contracted medical groups and health plans.
- Responsible for timely gathering of UM and PDR data and reports needed for internal and external audits which include, but are not limited to, CMS, DMHC, SFHP, and ATTEST data validation audits. Works closely with Compliance Officer and UM Director to ensure validity of data prior to submission.
- Ensure required documents are submitted to the CCHP QI Committee and Jade Health Care QA/UR Committee, approved and updated in applicable files. This includes gathering/revising UM & PDR policies and procedures and completing appropriate sections of quarterly work plans.
- Assure accurate and timely processing of the denial and pend letters and related correspondence by conducting monthly audits of denial/pend files in accordance with regulatory requirements. Prepare quarterly audit reports for submission to Committees. Communicate findings on a real-time basis to the UM nurses to prevent recurring deficiencies.
- Maintain updated knowledge in all aspects and transitions of departmental workflow, including state and federal requirements for UM and PDR functions.
- Monitor the ICE website for UM letter template updates.
- Serve as an internal resource (super-user) for department staff; assist others in learning functional features of Word, Excel, and Outlook as needed. Coordinate resolution of technical problems with the IT department as appropriate.
- Orient and train new UM coordinators and PDR Representative.
- Train new UM review nurses on the functions of the UM coordinators and the basics of our UM computer system.
- Train new PDR Specialist on the functions of the PDR Representative and the basics of our PDR computer system.
- Serve as subject matter expert and represent UM and PDR for core system build.
- Implement updates to the UM prior authorization process as directed, including documenting, disseminating and maintaining desk procedures to ensure coordination of operational changes.
- Implement updates to the PDR process as directed, including documenting, disseminating and maintaining desk procedures to ensure coordination of operational changes.
- Assist UM nurses to research health plan benefits, DOFRs, policies, criteria and/or guidelines.
- Facilitates or participates in process improvement initiatives by recommending improvements to business processes and policies and procedures. Maintains UM and PDR Department Master Policy and Procedure Manuals, ensuring they are the most up-to-date.
- May provide back-up administrative support for UM or QI Committees. Prepare and distribute agendas and supporting materials. Attend meetings and drafts minutes and correspondence. Communicates action items to responsible parties and follow-up on items to ensure completion.
- Also supports the Medical Director and the UM Director, which includes arranging meetings and calendar management, processing checks requests for vendor(s) invoices, and perform administrative duties as assigned.
- Accepts and performs other duties as assigned.
- Bachelor’s degree preferred or equivalent experience
- Advanced Excel skills required
- Two years experience working in a managed healthcare environment, preferably in the area of UM, QA or auditing
- Must be detail oriented
- Strong verbal and written communication skills required.
- Able to lift up to 30 pounds
- Use proper body mechanics when handling equipment
- Standing, walking and moving 50% of the day.
In our efforts to control the spread of COVID-19 and its variants, CCHP requires that its employees be fully vaccinated as of their start date. If you require a medical or religious accommodation we will engage in the interactive process with you. Proof of vaccination will be required prior to start. If we make you an offer and you are not yet vaccinated, we will accommodate a delay in start date. CCHP may also mandate that its employees receive vaccine boosters, and all accommodation laws will be followed.