UM Coordinator Denials

Astrana Health

Job Location:

Monterey Park, NM - USA

Hourly Salary: $ 21 - 26

Posted on: 30+ days ago

Vacancies: 1 Vacancy

Job Summary

Astrana Health is seeking a dedicated Utilization Management (UM) Coordinator Denials to join our Denial Department. This role ensures timely and accurate processing of all deferrals and denials in compliance with Astrana Health policies NCQA standards health plan requirements and federal and state regulations. The UM Coordinator Denials will review monitor and process prior authorization denials requests while maintaining strict adherence to regulatory and health plan guidelines.

Our Values:

Put Patients First
Empower Entrepreneurial Provider and Care Teams
Operate with Integrity & Excellence
Be Innovative
Work As One Team

Key Responsibilities

Adhere to Astrana Health policies and all applicable regulations including Health Plan DMHC DHCS CMS and NCQA standards.
Process and attach deferrals denials and associated documentation accurately. Review eligibility and benefits verification.
Manage provider and interdepartmental communications delivering excellent customer service. Accurately review and process daily deferrals and denials in accordance with IPA and health plan turnaround guidelines.
Review and process assigned deferrals or denials (e.g. denial modify carve-out) in compliance with policies accreditation and regulatory standards.
Verify member eligibility benefits and deferral/denial requirements.
Maintain accurate UM/Denial system data and meet turnaround time standards.
Apply appropriate denial templates based on Health Plan Line of Business (LOB) and threshold language.
Ensure correct criteria are used according to hierarchy and LOB utilizing only approved standards.
Verify that denial verbiage is written at the appropriate reading ease and grade level based on LOB.
Ensure denial packets are complete before finalization including denial letter authorization request proof of receipt clinical guidelines and medical records.
Assist with Failed Fax Reports Denial Inquiries and Appeal/Grievance Inquiries.
Report activities or issues to the UM Denial Supervisor/Manager throughout the day. Maintain a high level of integrity and confidentiality ensuring compliance with HIPAA standards. Collaborate with UM department and participate in quality improvement initiatives.
Perform other duties as required to support the department.

Qualifications

High school diploma or GED required.
Knowledge of medical terminology ICD-10 CPT HCPCS and RVS codes.
Proficient in Microsoft Office and UM software (e.g. InterQual MCG).
Strong organizational decision-making and problem-solving skills.
Excellent verbal and written communication.
Able to work effectively in a fast-paced team environment.
Minimum typing speed of 40 wpm.
Preferred:
- 2 year with a Health Plan or MSO.
- Experience with health plans managed care organizations or hospital UM departments
- Familiarity with Health Plan DMHC DHCS CMS and NCQA requirements.
- Ability to prioritize and delegate tasks effectively.

Environmental Job Requirements and Working Conditions

This is a hybrid position. The position will be fully in-office for 3 month probationary period. After successful completion of probationary period this position will possibly transition to 2 days in-office and 3 days at home per employee performance. The position is located at 1600 Corporate Center Dr Monterey Park CA 91754.
This position requires open availability M-Su 8 A - 8 P. Weekends and holidays are rotated amongst the team and there is mandatory overtime in this position.
The national target pay range for this role is $21.00 - $26.00 per hour. Actual compensation will be based on geographic location (current or future) experience and other job-related factors.

Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race religion color national origin gender (including pregnancy childbirth or related medical conditions) sexual orientation gender identity gender expression age status as a protected veteran status as an individual with a disability or other applicable legally protected characteristics. All employment is decided based on qualifications merit and business need. If you require assistance in applying for open positions due to a disability please email us at to request an accommodation.

Additional Information:

The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.

Required Experience:

Put Patients First
Empower Entrepreneurial Provider and Care Teams
Operate with Integrity & Excellence
Be Innovative
Work As One Team

Key Responsibilities

Adhere to Astrana Health policies and all applicable regulations including Health Plan DMHC DHCS CMS and NCQA standards.
Process and attach deferrals denials and associated documentation accurately. Review eligibility and benefits verification.
Manage provider and interdepartmental communications delivering excellent customer service. Accurately review and process daily deferrals and denials in accordance with IPA and health plan turnaround guidelines.
Review and process assigned deferrals or denials (e.g. denial modify carve-out) in compliance with policies accreditation and regulatory standards.
Verify member eligibility benefits and deferral/denial requirements.
Maintain accurate UM/Denial system data and meet turnaround time standards.
Apply appropriate denial templates based on Health Plan Line of Business (LOB) and threshold language.
Ensure correct criteria are used according to hierarchy and LOB utilizing only approved standards.
Verify that denial verbiage is written at the appropriate reading ease and grade level based on LOB.
Ensure denial packets are complete before finalization including denial letter authorization request proof of receipt clinical guidelines and medical records.
Assist with Failed Fax Reports Denial Inquiries and Appeal/Grievance Inquiries.
Report activities or issues to the UM Denial Supervisor/Manager throughout the day. Maintain a high level of integrity and confidentiality ensuring compliance with HIPAA standards. Collaborate with UM department and participate in quality improvement initiatives.
Perform other duties as required to support the department.

Qualifications

High school diploma or GED required.
Knowledge of medical terminology ICD-10 CPT HCPCS and RVS codes.
Proficient in Microsoft Office and UM software (e.g. InterQual MCG).
Strong organizational decision-making and problem-solving skills.
Excellent verbal and written communication.
Able to work effectively in a fast-paced team environment.
Minimum typing speed of 40 wpm.
Preferred:
- 2 year with a Health Plan or MSO.
- Experience with health plans managed care organizations or hospital UM departments
- Familiarity with Health Plan DMHC DHCS CMS and NCQA requirements.
- Ability to prioritize and delegate tasks effectively.

Environmental Job Requirements and Working Conditions

This is a hybrid position. The position will be fully in-office for 3 month probationary period. After successful completion of probationary period this position will possibly transition to 2 days in-office and 3 days at home per employee performance. The position is located at 1600 Corporate Center Dr Monterey Park CA 91754.
This position requires open availability M-Su 8 A - 8 P. Weekends and holidays are rotated amongst the team and there is mandatory overtime in this position.
The national target pay range for this role is $21.00 - $26.00 per hour. Actual compensation will be based on geographic location (current or future) experience and other job-related factors.

Additional Information:

Required Experience: