Sharp HealthCare · 21 hours ago
Utilization Management Resource Coordinator - Sharp Spectrum Corporate Offices - Full-Time - Variable Shift
San Diego, CA
Full-time
Onsite
Entry, Mid Level
$28.17/hr - $39.43/hr
2+ years expSharp HealthCare is a leading healthcare provider, and they are seeking a Utilization Management Resource Coordinator to support their centralized utilization management department. The role involves facilitating communication between department staff and external customers, ensuring timely follow-up on payer requests, and assisting in the management of clinical documentation and authorizations.
Health CareNon Profit
Responsibilities
Monitor Utilization Management Queues
Verifies current insurance plan eligibility
Reviews patient list and prioritizes/plans for the day
Contributes to the continuous improvement initiatives of the system centralized utilization management team to deliver quality interventions in a timely manner
Maintains proactive communications with insurance representatives, UM CM’s and TP CM teams at the site level
Maintains a current payer contact list to support utilization management activities
Maintains passwords and access to payer portals to ensure timely UM authorization capture
Acts as facilitator between payors and UM team members
Ensures UM team members are updated daily and thought out the day as needed
Keeps the ICM UM Leadership aware of inability to complete assigned duties or tasks
Responsible for timely and accurate retrieval and appropriate action on departmental phone messages and necessary fax communication
Work closely with revenue cycle to ensure the latest reimbursement and contract information is available to the utilization managers
Work closely with the revenue cycle to make sure all are aware of denials real time
Assists with the processing of letters of authorization, appeal or denial
Prepare databases and written reports for leads, manager, and director in a timely manner as requested and within the scope of work
Initiates and participates in the creation and development of forms and lists
Assist UM case managers and physician advisors with denial cases, setting up peer to peer reviews as needed
Must demonstrate attention to detail and accuracy
Ensures UM staff have appropriate resources and information to expedite smooth transition to through continuum and optimize third party payer reimbursement
Monitor authorization for all patients in-house to ensure reimbursement and payment for correct level of care
Monitor completion of retro reviews and notifies lead of reviews pending by noon the second business day of the request
Provide needed documentation for Medi-Cal TAR free process, and complete TARs timely for those patients who are not appropriate for the TAR free process
Attends department meetings
Initiates and participates in huddles and quality improvement activities
All work is consistently completed on time and in a timely manner
Confirm discharges from previous day and ensure that authorizations or denials are captured and documented
Documents activities as per the departmental processes and with the electronic medical record
Obtain detailed benefit coverage for complex requests specific to patient plan coverage
Investigate and follow-up on all eligibility issues in accordance with hospital guidelines
Performs review of all prior authorizations, entering into the electronic medical record
Researches and assists in the denial process-gathers documentation for the UR lead, director, and attending physician
Obtain detailed benefit coverage for the more complex requests for service specific to member plan coverage
Apply the principles of SCMG guidelines and Health Plan benefit guidelines to approve referrals designated at the CRC level
Investigate and follow-up on all eligibility issues in accordance with health plan and SCMG guidelines
Process referrals for prior authorization
Coordinate, review and process the more complex referrals for prior authorization for medical care and services, including emergency room, inpatient admission, durable medical equipment, home care and other miscellaneous services for the efficient and effective delivery of inpatient services
Performs review of all prior authorization referrals
Obtains necessary medical information for use by themselves, Medical Directors, the Hospitalist Physician and/or Case Manager
Identifies and refer requests for review by higher level staff (Medical Director, Hospitalist or HCM) within department turn around time (TAT) standards
Research and assist in the denial process - gathers documentation after review by medical director, ensure packet information is complete, assesses and select the appropriate denial reason
Maintain mandated TAT for denials
Obtains and gathers clinical information from multiple sources including use of Sharp and/or Hospital applications to retrieve patient medical records for review by Hospitalist Case Managers, SNF's or outpatient service providers
Verifies and documents eligibility and benefit details
Obtains prior authorizations for specific medications, through SCMG Pharmacy or through the patient's health plan when applicable
Has all information available to help with the review process
Informs and distributes health plan criteria to the Medical Director, CM or themselves to make a determination regarding an authorization for service or equipment
Updates inpatient IDX referrals with correct diagnoses, bed type and disposition
Generates or assist in the dissemination of Case Management Referrals
Generate informational referrals for patients that are accepted to hospice while admitted as inpatient
Research and interpret all ICD-10, CPT and HCPC coding using appropriate tools
Make determination on the more complex claims that are designated CC authorization level within SCMG TAT guidelines
Coordinates, reviews and processes more complex retrospective claims for medical care and services, including, SNF inpatient admission, medical transportation, durable medical equipment and other miscellaneous services for the efficient and effective facilitation of claim adjudication
Tracks and informs identified personnel of expired patients
Actively identifies gaps in skills and competencies and participated in seminars/classes to enhance gaps
Attends and actively participates in department/team process/quality improvement activities
Actively participates in all-staff meetings and stand-ups
Qualification
Required
H.S. Diploma or Equivalent
Preferred
Other Health related education
Other Successful completion of Medical Assistant Program or equivalent
2 Years hospital experience
2 Years Medi-Cal experience
Bilingual preferred
Knowledge of hospital payors preferred
General filing knowledge
Demonstrated proficiency in Microsoft Word, Microsoft Excel, Microsoft Outlook, and other software programs
Excellent organization, managerial and time management skills with the ability to multi-task
Excellent analytical, problem solving and supervisory skills, knowledgeable of medical terminology, and current standards of clinical practice, professional counseling, mentorship and resource allocation
Knowledgeable in the use of ICD-10, CPT4, and HCPC coding systems
Proficient in typing and computer data entry (45 wpm)
Excellent verbal and written communication skills
Ability to read, speak, and hear English clearly
Able to work independently in research and decision making with minimal direction from higher level of staff
Company
Sharp HealthCare
Sharp HealthCare is a not-for-profit integrated regional health care delivery system based in San Diego, Calif.
10001+ employees
Funding
Current Stage
Late StageTotal Funding
unknownKey Investors
Parkinson's Foundation
2023-07-25Grant
Leadership Team
Dan Exley
Vice President of Clinical Systems
Recent News
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2025-12-27
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