Job Description

Position Summary

The Utilization Management (UM) Coordinator is responsible for coordinating prior authorization requests, processing referrals, documenting case activity, and supporting timely utilization review activities using the EZCAP Authorization System. The coordinator ensures compliance with CMS, DHCS, NCQA, and contracted health plan requirements while maintaining excellent customer service to providers, members, and internal departments.

The UM Coordinator serves as the first point of contact for authorization requests and works closely with nurses, medical directors, case managers, provider offices, and health plans to ensure timely and accurate processing of requests.

Essential Duties and Responsibilities

Authorization Management

Receive and process prior authorization requests through EZCAP.
Verify member eligibility and health plan benefits.
Verify provider participation and network status.
Determine whether requests qualify for auto-approval.
Create new authorization records in EZCAP.
Enter accurate clinical and demographic information.
Assign requests to the appropriate review queue.
Prioritize urgent and expedited requests according to CMS requirements.
Maintain authorization documentation throughout the review process.
Process duplicate and corrected authorization requests.

EZCAP Responsibilities

Create and update authorization cases.
Document all provider communications.
Upload supporting medical records.
Scan and attach incoming documentation.
Monitor pending authorization queues.
Update authorization status throughout the review process.
Route cases to UM Nurses and Medical Directors.
Complete authorization closure after determination.
Document letter mailing information.
Verify authorization history.

Provider Communication

Receive incoming provider telephone calls.
Respond to fax and portal authorization requests.
Obtain missing clinical documentation.
Notify providers of additional information requests.
Communicate authorization determinations.
Escalate clinical questions to UM Nurses.
Coordinate with provider offices regarding duplicate requests.

Documentation

Accurately document:

Date and time of request
Source of request
Clinical information received
Carve-out determination source
Communication attempts
Fax confirmations
Telephone conversations
Medical record receipt
Provider follow-up
Authorization status changes

Regulatory Compliance

Maintain compliance with:

CMS Medicare Advantage regulations
NCQA Utilization Management Standards
DHCS Managed Care requirements
Knox-Keene Act requirements
Health plan contractual requirements
Organization UM Policies and Procedures
HIPAA Privacy and Security requirements

Turnaround Time (TAT) Monitoring

Monitor authorization turnaround times including:

Urgent requests
Standard requests
Additional information requests
Extension notifications
Pending authorizations
Escalations approaching regulatory deadlines

Quality Responsibilities

Maintain complete authorization documentation.
Follow departmental workflows.
Meet production standards.
Meet quality standards.
Participate in internal audits.
Correct identified documentation errors.
Attend required training sessions.
Assist with audit preparation.

Daily Responsibilities

Review incoming authorization queue.
Process fax requests.
Process portal requests.
Monitor urgent authorization requests.
Follow up on pending cases.
Upload clinical documentation.
Document provider communication.
Monitor worklists.
Assist nurses with non-clinical tasks.
Complete assigned production goals.

Required Knowledge

Knowledge of:

Medical terminology
ICD-10 diagnosis coding
CPT/HCPCS procedure coding
Prior authorization processes
Medicare Advantage
Managed Care operations
HIPAA regulations
CMS regulations
NCQA standards

Knowledge of EZCAP preferred.

Required Skills

Excellent communication skills
Strong organizational skills
Time management
Attention to detail
Data entry accuracy
Customer service
Critical thinking
Multitasking
Problem solving
Ability to prioritize urgent work

Minimum Qualifications

Education

High School Diploma or GED required
Associate degree preferred

Experience

Minimum 1 year in healthcare
Prior authorization experience preferred
Managed care experience preferred
Medical office experience preferred
Health plan experience preferred

Computer Skills

Experience with:

EZCAP Authorization System (preferred)
Microsoft Outlook
Microsoft Word
Microsoft Excel
Adobe Acrobat
Electronic Fax Systems
Electronic Health Records (EHR)
Health Plan Provider Portals

Performance Expectations

The UM Coordinator is expected to:

Meet departmental productivity goals.
Maintain a quality score of 95% or higher.
Process authorizations within regulatory turnaround times.
Accurately document all authorization activities.
Follow all departmental policies and workflows.
Maintain confidentiality of Protected Health Information (PHI).
Demonstrate professionalism with providers, members, and coworkers.

AMM BENEFITS

When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:

Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan.
Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe.
Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.
Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work.
Career Development: Tuition reimbursement to support your education and growth.
Team Fun: Paid company outings and lunches because we work hard, but we also know how to have fun!

Advanced Medical Management

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