While taking direction from the Manager of UM, the UM Coordinator helps daily to prioritize, coordinate, and implement utilization, discharge planning, regulatory and compliance activities with the UM team. The UM Coordinator revises UM policies/procedures particularly related to government regulations and compliance. The UM Coordinator will coordinate utilization and regulatory audit activities. This position will coordinate with the Manager, UM staff education and orientation. Attends/reports ... more details
Part-Time / 20 Hours / Days (2 days one wk / 3 days next wk)
Remote
SummaCare is a Summa Health entity that offers health insurance in northern Ohio. As a regional, provider-owned health plan, SummaCare is based in Akron, Ohio, and provides Medicare Advantage, individual and family and commercial insurance plans. SummaCare has one of the highest rated Medicare Advantage plans in the state of Ohio, with a 4.5 out of 5-Star rating for 2024 by the Centers for Medicare and Medicaid Services (CMS). Known for its excellent customer service and personalized attention to members, SummaCare is committed to building lasting relationships. Employees can expect competitive pay and benefits.
Summary:
While taking direction from the Manager of UM, the UM Coordinator helps daily to prioritize, coordinate, and implement utilization, discharge planning, regulatory and compliance activities with the UM team. The UM Coordinator revises UM policies/procedures particularly related to government regulations and compliance. The UM Coordinator will coordinate utilization and regulatory audit activities. This position will coordinate with the Manager, UM staff education and orientation. Attends/reports utilization information to the Utilization Committee as assigned. This roles supports the Utilization Medical Policy Committee and creates New Technology policies for committee review. Using critical thinking and analytics reviews utilization activities and reports to make recommendations for improvement to the Manager, UM. Performs high-cost/high utilization analysis and post service audits. By using Interqual criteria, policies, regulatory guidelines and other standards of care, the Coordinator for Utilization Management (UM) will collaborate with other health care providers to evaluate the appropriateness of utilization and the medical necessity of care, for elective and emergency admissions, surgeries, diagnostic procedures and treatments. The Coordinator for UM will facilitate ensuring the delivery of services takes place in the most appropriate setting, and provide support for transitions across the continuum of care for plan members that supports member experience, quality outcomes, organizational goals, and compliance with regulatory requirements.
Formal Education required: a) Graduate of an accredited school of professional nursing or a school accepted for candidacy status from an accrediting body. b) State of Ohio RN licensure c) Bachelor Degree preferred d) CCM/ACM certification or equivalent preferred e) NCQA experience preferred
Experience & Training Required: a) Minimum of 3 years performing same or similar responsibilities. Relevant experience includes previous industry, utilization management/utilization review experience and care coordination. b) Must have knowledge of InterQual criteria and its application.
3) Other Skills, Competencies and Qualifications: a) Strong clinical and assessment skills for a variety of patient populations. b) Demonstrates leadership skills c) Basic typing/computer skills needed to collect, assess, and enter data. d) Proficient using Microsoft Office, Word, Excel, and Powerpoint e) Demonstrate knowledge and skills necessary to provide care appropriate to the age of the members serviced. Takes ownership in identifying and obtaining education and training needed to meet needs of the members. f) Organize and manage time to accurately complete tasks within designated periods in fast-paced environment. g) Maintain current knowledge and application of industry regulatory requirements (NCQA, state regulatory, CMS), and company policies & procedures. h) Flexible: ability to adjust work hours to meet business demands. i) Ability to effectively interact with populations of members/customers with an understanding of their needs for self-respect and dignity j) Excellent verbal and written skills
4) Level of Physical Demands: a) Sit and/or stand for prolonged periods. b) Bend, stoop, and stretch. c) Lift up to 20 pounds. d) Manual dexterity to operate computer, phone, and standard office machines.
$33.66/hr - $50.49/hr
The salary range on this job posting/advertising is base salary exclusive of any bonuses or differentials. Many factors, such as years of relevant experience and geographical location are considered when determining the starting rate of pay. We believe in the importance of pay equity and consider internal equity of our current team members when determining offers. Please keep in mind that the range that is listed is the full base salary range. Hiring at the maximum of the range would not be typical.
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