Under the general supervision of the UM/QI Director, the UM Coordinator is responsible for processing phone, fax, and electronic authorization requests for medical services from physicians and hospitals (providers) in an efficient, accurate and customer-focused manner.  This position will also assist healthcare providers in ensuring compliance as established by program guidelines.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES

Effectively handles authorization requests and inquiry phone calls from providers, balancing excellent customer service with efficiency and established turn-around times.  Follows appropriate procedures for checking member eligibility, authorization history, and the status of provider participation within the contracted network.  Based on the information provided by the provider and gathered from computer systems, determines the appropriate handling of each request.  Utilizing accepted protocol, determines authorization requirements based on the type of service requested, the location of the service, and the provider specifics.  Inputs review data into systems with minimal errors.  Based on authorization rules and urgency, either approves the authorization request, or sends the nurse for review.  Communicates authorization specifics to providers and members either verbally through phone calls or written through fax or mailed letters.  Interprets a variety of instructions furnished in written and oral forms.  Assists in preparing and submitting projects, reports or assignments as needed to meet department initiatives and/or objectives.  Assumes responsibility for professional development of self and assists with training other staff members to contribute to their professional development.  Attend meetings as assigned.  Meet with staff at various health centers as assigned.

Performs other duties as assigned including participation in all safety programs which may include assignment to an emergency response team.