UMC II

River City Medical Group - Sacramento, CA2.9

30+ days ago
Who We Are

River City Medical Group (RCMG) is a progressive Independent Physician Association (IPA) of over 700 physicians uniquely dedicated to serving over 170,000 members within Sacramento’s Medi-Cal population. Founded by longtime community physicians in 1992, it is our mission to not only understand the needs of our diverse communities, but to address them with creative and culturally sensitive health care solutions. RCMG serves as a supportive link between health plans, providers, and the members with a dedication to ensuring our entire health care delivery process operates smoother.

With over 230 dedicated employees and growing, RCMG is an active member of the community helping to support it in our professional roles as an IPA. With the robust leadership of local practicing physicians, we are committed to ensuring our members and physicians are supported to provide the right care at the right time.

A dedicated team implementing creative solutions to assist providers with focusing more on patient care and less on administration

Community relations developing public and private partnerships that improve access to care and link members to services

Doctors providing care to almost 1 in 2 Medi-Cal Beneficiaries in the Sacramento area

Only IPA based in Sacramento County exclusively dedicated to serving the Medi-Cal population

It is the policy of RCMG to provide equal employment opportunity (EEO) to all persons regardless of age, color, national origin, citizenship status, physical or mental disability, race, religion, creed, gender, sex, sexual orientation, gender identity and/or expression, genetic information, marital status, status with regard to public assistance, veteran status, or any other characteristic protected by federal, state or local law. In addition, RCMG will provide reasonable accommodations for qualified individuals with disabilities.

Job Summary

The Utilization Management Coordinator coordinates and supports activities related to authorization processing for office visit, outpatient, inpatient, ambulatory services and generates Delay/Modify/Denied Letters using approved outlined letter templates.

Responsibilities

Receives and processes all incoming referrals within established turnaround times and production standards to include all necessary guidelines, limits and information to complete.
Notifies UM/QM Manager of ESRD, AIDS, hospice, transplants and other relevant areas of concern. Utilizes chronic condition code(s) in QuickCap (portal) System.
Effectively works with providers, nurses, case managers, and Medical Directors to ensure system inputs of electronic and manual referrals are processed, timely, accurately and within production standards.
Excellent oral and written communications skills with strong analytical and problem solving skills
Receives and enters appropriate information from referrals.
Obtains appropriate information for authorization request entry and request clinical records per procedure(s).
Refers requests and notification to appropriately licensed health professional for review.
Generates Delay, Modify and Denial Letters with accuracy and approved requirements, including regulatory language, address, phone/fax numbers and translated language.
Write and disseminate compliance communications to all levels of the organization to ensure support, awareness and effectiveness of compliance program.
Researches and analyzes regulatory requirements as needed to ensure compliance.
Interacts with other department personnel to ensure coordinated efforts. Maintains an appropriate, professional demeanor at all times.
Coordinates care for members between PCP, CCS providers and other physicians and providers as needed.
Assist in the coordination of responses for Corrective Action Plans, inquiries, follow-up, reporting and any other request.
Assist in the preparation of materials and requirements for regulatory audits.
Identifies membership discrepancies, eligibility issues, and group contract issues for resolution by Service Representatives. Provides and documents continuous follow-up on open issues.
Reviews eligibility reports and identifies all changes to eligibility (additions, terminations, and/or contract changes) and processes all resulting transactions.
Answers telephone in a prompt, professional, courteous and helpful manner; screens and directs calls to appropriate staff member or department. Responds to routine requests and completes customer service tickets daily while maintaining an accurate phone call log.
Assists with examination of records, related documents, corresponds with providers and health plan personnel to obtain facts regarding member concerns/complaints.
Creates, approves, and modifies referrals in accordance with established guidelines.
Verifies member eligibility by systems inquiry or health plan contact.
Requests clinical records per procedure.
Demonstrates a comprehensive knowledge of Health Plan Benefits, DOFR, and the various departmental functions.
Accurately applies appropriate policies, procedures, and eligibility and benefit policies.
Maintains current knowledge of provider network as it continues to develop and change.
Leads projects assigned by designing and effective process, conducting the necessary research to put together and implement an effective project plan to, monitor and implement department and cross-functional projects.
Meets or exceeds established performance goals including but not limited to service, quality, productivity, and Turn-Around Time.
Effectively manages projects and objectives in a timely manner.
Develops positive and professional working relationships with providers, nurses, case managers, and Medical Directors to ensure system inputs of electronic and manual referrals are processed, timely, accurately and within production standards.
Adheres to company policies, procedures, guidelines and directives. Recognizes and enforces company security measures, maintains strict confidentiality and complies with HIPPA standards.
Enhances professional growth and development through in-service meetings and educational programs.
Assist department in identifying opportunities for workflow improvements.
Assist in the preparation of materials and requirements for regulatory audits.
Drives the process to implement regulatory requirements, updates and changes though the portal.
Contributes to a healthy, positive and safe environment while promoting self as a team member.
Performs related duties consistent with the scope and intent of the position.
Regular attendance.
Performs required clerical support duties
Maintains strict confidentiality
Travel as required
Educational/License Requirements

High School Diploma or GDE required.
BA/BS degree in related field is preferred.
Medical Assistant Diploma/Certification preferred.
Qualifications and Experience
Minimum of 3 years’ experience in a health care, customer service or a manage care setting required.
Minimum of 2-3 years’ experience in Utilization Management coordination required.
Minimum of 3years’ experience in the medical field is required.
Ability to type a minimum of 45 WPM.
Ability to professionally and efficiently manages intake activities.
Ability to multi-task, problem solve and analyze data in a fast paced environment.
Ability to intervene and diffuse difficult calls.
Demonstrated ability to assess, evaluate and interpret medical information.
Proficiency with computer and standard business software (MS Office applications) and ability to learn in-house and other systems quickly with minimal training.
Excellent communication skills, including both oral and written.
Excellent active listening and critical thinking skills.
Ability to multi-task, exercise excellent time management, and meet multiple deadlines.
Ability to provide and receive constructive job and/or industry related feedback.
Ability to maintain confidentiality and appropriately share information on a need to know basis.
Ability to consistently deliver excellent customer service.
Excellent attention to detail and ability to document information accurately.
Ability to effectively and positively work in a dynamic, fast-paced team environment and achieve objectives.
Demonstrate commitment to the organization’s mission.
Must have mid-level skills in Microsoft software (Word, Excel, PowerPoint).
Must have the ability to quickly learn and use new software tools.
Must have mid-level skills using e-mail applications.
Self-motivated with strong organizational, multi-tasking, planning, and follow up skills.
Ability to work independently as well as in a team environment.
Ability to present self in a professional manner and represent the Company image.