Medical Management Care Coordinator I

Medical Management Care Coordinator I

Salary Range : $54,647 - $79,237

The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change.

FLSA Status : Non-Exempt

Department : Health Services

Reports To : Supervisor, Utilization Management

Employee Unit : Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521

GENERAL DESCRIPTION OF POSITION

The Medical Management Care Coordinator I performs non-clinical supportive duties related to utilization management (UM) and care coordination for Santa Clara Family Health Plan (SCFHP) members. Routine supportive duties include but are not limited to data entry into system software applications, managing department telephone queues, and assisting with quality monitoring projects for both SCFHP lines of business in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, Care Coordinator Guidelines and business requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

• Follow established Health Services policies and procedures and use available resources to respond to member and / or provider inquiries and resolve any concerns in an accurate, timely, respectful, professional and culturally competent manner
• Collaborate with team members on improvement efforts across-departments regarding quality improvement projects, optimization of utilization management, and member satisfaction.
• Develop effective and professional working relationships with internal and external stakeholders and partners. Communicate effectively with members and providers orally and in writing.
• Assist in gathering and processing data for internal required reports and analysis.
• Attend and actively participate in daily, weekly, and monthly departmental meetings, in-services, training and coaching sessions.
• Follow UM policies and processes to the management of incoming authorization requests received through fax, mail or telephone.
• Identify authorization requests for line-of-business, urgency level, type of service, and assess for complete / incomplete record submission.
• Perform complete, accurate, and consistent data entry into system software applications in accordance with policies, procedures and instruction from UM management.
• Answer inbound UM phone queue calls timely to assist members and / or providers regarding inquiries involving authorizations, SCFHP program services, and / or benefits.
• Process written and verbal notifications of authorization determinations to members and / or providers within regulatory processing timeframes.
• Perform other duties as required or assigned.

REQUIREMENTS - Required (R) Desired (D)

The requirements listed below are representative of the knowledge, skill, and / or ability required or desired.

WORKING CONDITIONS

Duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.

PHYSICAL REQUIREMENTS

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation :

ENVIRONMENTAL CONDITIONS

General office conditions. May be exposed to moderate noise levels.

EOE

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