Utilization Management Coordinator

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☕ Washington – Remote

☕ Washington – Remote

💵 $21 - $28 / hour

⏰ Full Time

🟢 Junior

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Community Health Plan of Washington

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1992

⚕️ Healthcare Insurance

👥 B2C

Healthcare Insurance • B2C

Community Health Plan of Washington is a nonprofit health plan founded in 1992 by Washington’s community health centers that provides Medicaid (Apple Health), Medicare Advantage, Dual-eligible, and Individual & Family insurance plans across Washington state. It offers care management, behavioral health, virtual care, member support and community services, and programs such as rewards, language assistance, and provider networks to serve members and community health needs.

📋 Description

• Performs data entry for all referral, prior authorizations and hospital notifications; attaches and/or includes clinical documents as needed • Utilizes knowledge to determine appropriate CPT, HCPC, ICD-10 codes using CMS, NCQA and HCA criteria • Researches and validates benefit and prior authorization requirements to determine appropriate course of action within the Care Management system • Reviews, corrects, and approves authorization requests via the web portal; determines appropriate level of complexity and refers cases requiring clinical review to a nurse reviewer • Reviews completed denial letters for accuracy and adherence to compliance deadlines • Edits and proofreads content for appropriate medical terminology and MCG criteria • Ensures letters are mailed within established timeframes • Accurately applies policies & procedures, benefit and eligibility standards to all incoming requests • Conducts research, validates data, and responds to complex inquiries from multiple sources, including but not limited to members, nurses, medical providers, customer service, operations, appeals, case management and care coordination

🎯 Requirements

• Have an associate degree, or an equivalent combination of education and highly relevant experience • Have at least one (1) year of customer service experience, preferred • Have working experience in a Healthcare setting, preferred • Have working experience in a Managed Care setting, preferred • Are knowledgeable of medical terminology and healthcare processes, preferred • Are knowledgeable of Washington Apple Health and Medicare Advantage Plans, preferred

🏖️ Benefits

• Medical, Prescription, Dental, and Vision • Telehealth app • Flexible Spending Accounts, Health Savings Accounts • Basic Life AD&D, Short and Long-Term Disability • Voluntary Life, Critical Care, and Long-Term Care Insurance • 401(k) Retirement and generous employer match • Employee Assistance Program and Mental Fitness app • Financial Coaching, Identity Theft Protection • Time off including PTO accrual starting at 17 days per year • 40 hours Community Service volunteer time • 10 standard holidays, 2 floating holidays • Compassion time off, jury duty