UM Coordinator, Inpatient
San Francisco Health Plan - San Francisco, CA

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POSITION TITLE: UM Coordinator - Inpatient Team

DEPARTMENT: Medical Management

FLSA STATUS: Non-Exempt

REPORTS TO: Manager, Inpatient UM Team

SUPERVISES: N/A

EVALUATION DATE: 7/2012

The Utilization Management Coordinator is responsible for working with a multi-disciplinary team, serving primarily in an administrative support capacity. The duties of this position include making telephone calls to members and providers, as well as data entry. The position provides opportunities to work on case management, disease management, community outreach projects and assisting with utilization management and pharmacy authorization requests, contingent upon departmental needs. This position will be cross-trained in several key positions within the Medical Management department.

ESSENTIAL DUTIES & RESPONSIBILITIES

Researches medical and pharmacy utilization management requests using a variety of resources including SFHP evidence of coverage, policies and procedures, electronic resources and medical journals.

Refers cases to a clinician, including the Medical Director, for clinical review, potential denial or modification and physician provider education

Provides administrative and clerical support for case management, disease management and utilization management activities

Maintains databases as needed for reporting requirements

Answers questions and resolves issues promptly from providers, office staff, and pharmacy staff pertaining to medical supply benefits, formulary and preauthorization requirements.

Ensure the privacy and security of PHI (Protected Health Information) as outlined in SFHP's policies and procedures relating to HIPAA compliance.

Makes telephone calls to members according to SFHP utilization, case and disease management program protocols.

Provide administrative assistance on a collaborative pilot project to call members with diabetes, coach them on self-management goals, and respond to “triggers” from an automated telephone self-management system.

Enters required data in various computer programs and databases.

Coordinates activities with the other members of the collaborative and attends required meetings.

Participates in making member phone calls working from a script, and identifying when calls need to be referred to a clinician for review.

Other responsibilities as assigned.

INDIVIDUAL CONTRIBUTOR EXPECTATIONS

Takes the necessary steps to ensure he/she understands the SFHP mission and its overarching business goals and objectives.

Acts with integrity, honesty and fairness, remaining mindful of the duty of trust SFHP has to it employees, and to its providers, employers and members.

Accepts and adapts to changes in SFHP policy, practice, procedures quickly and positively and proactively supports his/her colleagues in adapting to changes in the workplace.

Contributes actively and effectively to team discussions, sharing his/her knowledge and expertise willingly and collaboratively.

Takes steps to ensure he/she understands departmental performance competencies metrics. Strives daily to ensure his/her individual performance meets or exceed the performance competencies and metrics. Offers assistance to other members of the team as appropriate in order to help the team meet its overall metrics goals.

Focuses on providing outstanding customer service daily to both external and internal customers.

Suggests process improvements that can streamline and improve SFHP customer service.

Models professional behavior/conduct that remains in concert with the SFHP culture and business values. Leads by example whether in group or individual meetings.

CORE COMPETENCIES / KNOWLEDGE & SKILL REQUIREMENTS

Detail-oriented with problem-solving abilities

Knowledge and application of English grammar including composition, editing and proofreading skills.

Strong organization, time management and project management skills and multi-tasking abilities.

Ability to handle detailed work, work with varying types of data and maintain confidentiality.

Ability to display a courteous, patient, and helpful attitude toward employees.

Basic understanding of SFHP policies and procedures.

Bilingual verbal skills (e.g. Spanish or Cantonese) required, written skills a plus.

EDUCATION, EXPERIENCE & TRAINING REQUIRED

Current Medical Assistant Certification or California Pharmacy Technician License or equivalent experience in a health care field with familiarity with basic medical terminology and concepts, required.

A Bachelors degree in Social Sciences, Life Sciences, Business or a related field, preferred.

Experience with Medi-Cal and/or Department of Health Care Services regulations and standards, preferred.

Experience in an HMO or experience in a managed care setting, a plus.

Knowledge of and experience with state and federal insurance programs, a plus.

COMMUNICATION & INTERPERSONAL SKILLS

Must be able to understand fairly complex written and oral instructions.

Written:
Ability to clearly present written information and findings.

Verbal:
Ability to clearly communicate information.

Interpersonal:
Ability to interact well with co-workers and outside contacts.

SIGNIFICANT CONTACTS

Internal:
Customer Services and Medical Management staff.

External (if applicable):
Members and providers.

ESSENTIAL FUNCTIONS—PHYSICAL POSITION REQUIREMENTS; MACHINES AND/OR EQUIPMENT USED

Must be PC literate; MS Office skills (Word, Excel, PowerPoint).

Regularly required to operate standard office equipment (personal computer, photocopy machine, fax machine, etc.)

Ability to work on a computer up to 7 hours a day.

Regularly required to sit for long periods of time, and occasionally stand and walk.

Regularly required to use hands to operate computer and other office equipment.

Close vision required for computer usage.

Occasionally required to stoop, kneel, climb and lift up to 25 pounds.

WORKING CONDITIONS

Standard office environment without unpleasant or hazardous conditions. Work entails typical physical demands involved in office work.

NOTE: This description is not intended to be construed as an exhaustive list of duties, responsibilities or requirements for the position. This position may change or assume additional duties at any time. The employee may be requested to perform different or additional duties as assigned.

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