Responsible for maintaining and managing the internal and external utilization processes in a timely and accurate manner consistent with HealthCare Partners’ (HCP) policies and procedures as described in the Utilization Management Plan.
Consistently exhibits behavior and communication skills that demonstrate HealthCare Partners’ (HCP) commitment to superior customer service, including quality, care and concern with each and every internal and external customer.
Performs effective prospective and concurrent review of requested services according to established guidelines and timeframes.
Documents members’ service benefits by contacting the appropriate health plans as needed.
Directs providers/members to contracted provider network and facilities.
Processes appropriate authorizations for HMO/PPO clients as specified in the HCP procedures.
Prints and mails authorizations to providers, patients, HMOs and facilities as needed.
Assists and monitors in the processing of referrals. Enters, updates and closes referrals daily while assuring that appropriate internal/external referral providers are utilized, members are eligible and have benefits coverage, correct CPT/ICD-9 codes have been entered, accurate records of all dates and other required fields are entered, supporting clinical data for the referrals is entered, and all urgent referrals are processed within the designated timeframe.
Processes referrals for durable medical equipment and coordinates home health services according to established policies, procedures and guidelines.
Processes elective surgical requests including the coordination of surgery dates and notification of inpatient team, Hospitalist or Care Manager when appropriate.
Coordinates, identifies and routes referrals that require review to licensed Care Management staff who arranges outside physician medical review as appropriate.
Acts as a resource to other coordinators, staff and providers by resolving issues and responding to requests in a timely and effective manner.
Works with Patient Services regarding member concerns.
Processes referrals for inter-facility transfers using pre-established guidelines.
Processes after-hours emergency/urgent care logs/lists as needed.
Collects and prepares medical records for review when appropriate or as requested.
Assists with answering telephones and maintaining files, logs or other reports.
Uses, protects, and discloses HCP patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
Performs additional duties as assigned.
High school diploma, G.E.D. or equivalent. Includes special certification required for specific jobs.
Over 1 year and up to and including 3 years of experience.
3 to 5 years experience in a health care setting.
2 years referrals management or related experience.
KNOWLEDGE, SKILLS, ABILITIES:
Ability to type 30 wpm.
Knowledge of medical terminology and CPT/ICD-9 coding.
Excellent communication, organization and customer service skills.
Proven ability to problem-solve.
Strong attention to detail.
Ability to manage time effectively and work independently.
What's the first thing that happens when one of the leading independent medical groups in the country comes together with a global leader in health care? Opportunity. With DaVita Medical Group, HealthCare Partners, The Everett Clinic, Northwest Physicians Network, MountainView Medical Group and Magan Medical Clinic joining OptumCare and the UnitedHealth Group family of companies, people like you will find increasing levels of challenge, impact and professional success. We're changing health care for the better by improving access to affordable, high quality care, and working together to improve the patient experience. That takes passion, commitment, intense focus and the ability to contribute effectively in a highly collaborative team environment. Are you with us? Learn more about this exciting opportunity to do your life's best work.(SM)
Careers with OptumCare. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health - related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. OptumCare, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Here you’ll find incredible ideas in one incredible company and a singular opportunity to do your life's best work.(SM)
Diversity creates a healthier atmosphere: OptumCare and its affiliated medical practices are Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. OptumCare and its affiliated medical practices is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.