Utilization Management Assistant - Ambulatory
Company: St. Joseph Health
Posted on: June 6, 2021
We are looking for a Utilization Management Assistant for the
HSS Ambulatory UM Department at St. Joseph Heritage Healthcare.
Location: Hesperia, CA
Work Schedule: Full Time - 80 Biweekly Hours
Shift: 8-hour, Days
Under the direction of the Utilization Supervisor/ Manager, this
position is responsible for the distribution, review, accurate and
timely processing of SJHH patient referrals requested from
- Responsible for verification of member's eligibility (reporting
to enrollment if not in IDX) and checks benefits of members for
services requested per evidence of coverage guidelines.
- Performs preliminary review and assessment of referrals for
completeness: Supporting clinical documentation for the referral
request, ICD-10, CPT, or HCPC codes. Assists in gathering clinical
information needed to substantiate the medical necessity of the
- Ability to prioritize work, meet departmental productivity
standards and maintain compliance of 95% or greater for Turn
-Around-Time processing of referrals per ICE standards. This work
includes patient and provider notification of referral
- Referrals HMO as well as Non-HMO will be processed according to
the established SJHH internal process (electronic submission when
applicable) utilizing contracted vendors/providers as determined by
the Contracting Department and Leadership with an accuracy rate of
- Review and authorize all procedures on the SJHH Internal
Pass-Thru and UMA Sign-Off Lists. Complete data entry of referrals
in IDX, including those requiring escalation for nurse or physician
- Maintains files and documentation with an accuracy rate of 95%
or greater according to UM departmental standards.
- Communicates with physician offices, processing staff, and
other departments as needed to ensure collaboration and open
discussion regarding referral process. This includes responding to
messages within next business day with a compliance rate of 90% or
- Identifies and communicates to Lead/Supervisor or Manager any
trends/patterns that adversely impact flow, such as offices or
vendors not following established process for referral
- Assists in the denial letter process under the direction of the
nurse reviewer, UMA Lead or Supervisor when appropriate. Initiates
Information Member Notice based on benefit or eligibility.
- Moderate computer skills including Microsoft Windows, Word,
Excel, and an e-mail system required.
- Accurate typing of 45+ WPM required.
- Ability to work independently, self-prioritize workload and
functions well as part of a team.
- Ability to communicate both verbally and in writing in a clear
and concise manner.
- Knowledge of insurances and managed care.
- Demonstrates dependability.
- Must be able to work under general supervision.
- Demonstrates willingness to assist others.
- Must have a professional and mature demeanor.
- Must be able to work in a fast-paced department and handle
multiple tasks, work with interruptions, and deal effectively with
- Proficiency in MS Excel, Access and Word applications,
- Bilingual English/Spanish communication skills, preferred.
Minimum Position Requirements:
Education: H.S. Diploma or GED
Experience: One (1) year experience in a hospital, health
insurance company or medical office/clinic setting.
Preferred Position Qualifications:
Education: Coursework/Training - College level classes,
preferably in healthcare or related field or Associate's Degree in
Healthcare or related field
Experience: One (1) year experience in utilization management or
case management with experience in medical terminology and
Licenses/Certifications: MA Certification
Mission Heritage Medical Group is one of California's most
respected medical groups. With over 3,000 employees and 75
locations throughout California, including, Northern California,
Orange County, High Desert and Los Angeles County, Mission Heritage
Medical Group has been continually recognized as a leader in
quality, customer service and information technology. This kind of
success is the result of team work, a commitment to excellence and
a strong adherence to the organization's mission, vision and
values. Mission Heritage Medical Group provides equal employment
opportunities (EEO) to all employees and applicants for employment
without regard to race, color, religion, sex, national origin, age,
disability or genetics. In addition to federal law requirements,
Mission Heritage Medical Group complies with applicable state and
local laws governing nondiscrimination in employment in every
location in which the company has facilities. This policy applies
to all terms and conditions of employment, including recruiting,
hiring, placement, promotion, termination, layoff, recall,
transfer, leaves of absence, compensation and training.
Keywords: St. Joseph Health, Hesperia , Utilization Management Assistant - Ambulatory, Other , Hesperia, California
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