POSITION SUMMARY/ OBJECTIVE

Utilization Management Coordinator supports comprehensive coordination of medical services including intake, screening and referrals to Florida Community Care (FCC) case management, promotes/supports quality effectiveness of healthcare services.

All employees shall meet specified training programs including Compliance/Privacy Regulations, and attend at a minimum one (1) hour of Compliance/Privacy educational training annually, as required by Florida Community Care (FCC).

All employees shall meet Risk Management Regulations, and attend at the minimum one (1) hour of Risk Management education and training within the first thirty (30) days of employment and as required by law or Florida Community Care; and, for that non-physician in clinical direct care delivery services, annually thereafter.

All employees if duly licensed in the State of employment, and said license is part of requirement of their position with Florida Community Care, shall maintain in good standing and current state licensure.

All employees are required to maintain confidentiality, protect privacy, comply with PHI regulations, and report violations.

Essential duties and responsibilities include the following:

• Member Identification- Performs intake of calls from members or providers regarding services via telephone, fax, web portal
• Utilizes FCC systems to build, research and enter member information
• Screens requests for appropriate referral to medical services staff
• Approve services that do not require a medical review in accordance with the prior authorization grid
• Performs non-medical research including eligibility verification, COB, and benefits verification
• Documentation and Communication- Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements
• Promotes communication, both internally and externally to enhance effectiveness of medical management services (e.g., claim administrators, plan sponsors, and third-party payers as well as member, family, and health care team members respectively)
• Protects the confidentiality of member information and adheres to company policies regarding confidentiality
• Communicate with FCC case managers, when processing transactions for members active in this program
• Supports the administration of the precertification process in compliance with various laws and regulations, URAC and/or NCQA standards, where applicable, while adhering to company policy and procedures
• Places outbound calls to providers under the direction of medical management nurses to obtain clinical information for review of medical authorizations

• Minimum Education: High school diploma or G.E.D.
• Minimum Experience: 2-4 years of experience as a medical assistant, office assistant or other clinical experience.
• Managed care experience preferred (e.g., Medicaid, Medicare)
• Proficiency of Microsoft Office applications including Office, Excel, and Outlook.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands, reach with hands and arms; talk and hear. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Must be able to work in a stressful environment.

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.

In compliance with the Drug-Free Workplace Act of 1988, Florida Community Care has a longstanding commitment to provide a safe, quality-oriented and productive work environment. Alcohol and drug abuse poses a threat to the health and safety of FCC employees and members and to the security of the company's equipment and facilities. For these reasons, FCC is committed to the elimination of drug and alcohol use and abuse in the workplace.