We are seeking a Utilization Management Coordinator to join our team at Independent Living Systems (ILS). ILS, along with its affiliated health plans known as Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for all vulnerable populations.
About the Role:
The Utilization Management Coordinator plays an essential role in ensuring that the authorization requests are processed effectively. The Utilization Management Coordinator reviews the prior authorization form received for documentation completeness and determines if the requested service requires an authorization. This role includes inbound and outbound communication with both internal and external customers. Ultimately, the Utilization Management Coordinator contributes to improving member outcomes by facilitating timely access to necessary care.
Minimum Qualifications:
- High school diploma or equivalent required
- 2 years of experience as a medical office referral/authorization clerk, office assistant or other medical office experience.
- Strong knowledge of healthcare regulations, and medical terminology.
- Relevant experience may substitute for the educational requirement on a year-for-year basis.
Preferred Qualifications:
- Associate degree in Health Administration, or a related healthcare field
- Certification in Utilization Review (e.g., Certified Professional in Utilization Review - CPUR) or Case Management (e.g., CCM).
- Experience working within managed care organizations or health insurance companies.
- Familiarity with regulatory requirements such as Florida Medicaid/SMMC and CMS guidelines, HIPAA and current health plan accreditation standards,.
Responsibilities:
- Demonstrate commitment to Our Mission and models ILS Experience Standards of Excellence.
- Continuously reviews prior authorization requests received via oral, provider portal, fax and/or email to ensure timely processing.
- Screens prior authorization requests for appropriate referral to the Clinical Care Specialist.
- Performs non-medical research including eligibility verification, reviewing the prior authorization grid to confirm if services do or do not require prior authorization.
- Places outbound calls to providers to request clinical information for review.
- Perform other duties as assigned.
Skills Required
- High school diploma or equivalent
- 2 years of experience as a medical office referral/authorization clerk, office assistant, or other medical office experience
- Strong knowledge of healthcare regulations and medical terminology
- Relevant experience may substitute for educational requirement on a year-for-year basis
- Associate degree in Health Administration or related healthcare field
- Certification in Utilization Review (e.g., CPUR) or Case Management (e.g., CCM)
- Experience working within managed care organizations or health insurance companies
- Familiarity with Florida Medicaid/SMMC, CMS guidelines, HIPAA, and current health plan accreditation standards
What We Do
Independent Living Systems, LLC, offers a comprehensive range of clinical and third-party administrative services to managed care organizations and providers that serve high-cost, complex member populations in the Medicare, Medicaid and Dual-Eligible Market. Independent Living Systems has been an industry leader in managing home and community-based programs for over 16 years. Leveraging ILS’ award winning technology platform, ILS provides assistance beyond the clinical realm at every stage of care from hospitalization to the treatment of chronic illnesses to personalized care management including nutritional support. As one of the country’s leading providers of Nutritional Support Services and medically tailored meals, ILS provides nutrition counseling and home delivered meals for individuals transitioning from acute settings to the home as well as for those combatting the effects of one or more chronic diseases. In partnership with health plans, providers, hospitals, and pharmaceutical and medical device companies, ILS provides solutions aimed at improving health outcomes while rebalancing costs. ILS’ suite of products and services include: MLTSS - Managed Long-Term Services Supports Suite of solutions including assessments, care management, and coordination of home and community-based services, care planning, and back-office support CCM - Comprehensive Care Management A streamlined solution for ongoing care management and care optimization targeted towards special needs populations and special needs plans Meals and Nutrition One of the nation’s largest nutritional providers delivering consistent, high-quality therapeutic meals to elderly and at-risk populations TPA – Third Party Administration A fully integrated business and technology offering to support all administrative and financial reporting requirements of health plans and risk bearing entities MSO – Management Services Organization Population and provider-based interventions to address utilization and monitor unit costs of services For more information please contact us via email at [email protected].
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