Utilization Management Coordinator

About Consociate Health

Consociate Health is a premier Third-Party Administrator dedicated to enhancing career development within a supportive and innovative environment. We foster continuous learning and value the diverse ideas and perspectives of our employees. Our mission is to make healthcare more accessible and affordable through innovative solutions and expert guidance, guided by our core values of Compassion, Humility, and Impact, which enable us to build authentic relationships with our team and clients.

Position Summary

The Utilization Management Coordinator, reporting to the Director of Claims, plays a crucial role in managing the appeal process and utilization management (UM) activities. This includes initiating case management, requesting pre-certifications, facilitating medical reviews, and handling independent dispute resolutions. The ideal candidate will embody exceptional service, professionalism, and dedication.

Essential Duties and Responsibilities

• Compile, examine, and report on data related to member and provider appeals.
• Generate responses to written inquiries from employers, members, and providers, adhering to Department of Labor regulations and summary plan document stipulations.
• Maintain comprehensive records and logs for all appeal activities.
• Collaborate with managed care organizations, UM departments, and cost containment vendors to arrange reviews for medical necessity, including pre-determinations and retrospective assessments.
• Evaluate submissions from the Claims Department to ascertain the appropriateness of services based on established UM guidelines, trilogy, and summary plan document reviews.
• Actively contribute to meetings, including presenting reports and statistical data.
• Undertake other related duties and participate in special projects as assigned.

Benefits

• Paid time off
• Paid Holidays
• Medical, Dental, and Vision Insurance
• Basic Group Life, Short Term and Long Term Disability coverage
• Voluntary Life, Critical Illness, and Accident Coverage options
• 401K Plan: Immediate eligibility with a 2% automatic enrollment. Company match up to 4% of annual salary.

Required Experience and Skills

• Proficiency in administrative and technical tasks, with strong command of Microsoft Office Suite, Microsoft Teams, and telephone systems.
• Exceptional verbal and written communication abilities, comfortable with extended phone conversations and prompt email responses.
• Demonstrated trustworthiness and accountability, with the capacity to handle confidential personal information daily.
• Reliable attendance and punctuality, with flexibility to adjust schedules as needed, including occasional paid overtime.
• High School Diploma or GED equivalent.

General Expectations

• Consistently represent Consociate in a positive light.
• Deliver services with an attitude of respect and recognition for the inherent worth and dignity of every individual.
• Communicate clearly and concisely, employing active listening skills.
• Proactively identify and undertake tasks not explicitly assigned.
• Adhere to safety standards and employ proper techniques to prevent injuries.
• Actively seek opportunities for process improvement and suggest enhancements for efficiency.
• Foster a teamwork philosophy by collaborating effectively with colleagues.
• Attend all mandatory in-service training and staff meetings.
• Maintain strict confidentiality of all business-sensitive information, including that of insured groups, individuals, employees, and applicants.

Physical and Mental Abilities

• Capacity for sedentary work over extended periods.
• Ability to operate a personal computer, telephone system, and interact with team members.
• Capability to concentrate, meet deadlines, manage multiple projects concurrently, and adapt to interruptions.

Working Conditions

• This is a fully remote position.
• Any offsite work must comply with HIPAA regulations.