Medical Management Care Coordinator

Santa Clara Family Health Plan
Published
August 13, 2019
Location
San Jose, CA
Category
Job Type

Description

Consider a career at Santa Clara Family Health Plan a public, not-for-profit plan of over 250,000 members.  

GENERAL DESCRIPTION OF POSITION
The Medical Management Care Coordinator performs non-clinical supportive duties related to utilization management (UM) and care coordination for SCFHP members. Routine supportive duties include but are not limited to data entry into system software applications, managing department telephone queues and assisting with quality monitoring projects for all SCFHP lines of business in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, Care Coordinator Guidelines and business requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES

  1. To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily.
  2. Follow established Health Services policies and procedures and use available resources to respond to member and/or provider inquiries and resolve any concerns in an accurate, timely, respectful, professional and culturally competent manner.
  3. Perform complete, accurate and consistent data entry into system software applications in accordance with policies, procedures and instruction from Health Services Management.
  4. Collaborate with team members on improvement efforts across-departments regarding quality improvement projects, optimization of utilization management, and member satisfaction.
  5. Develop effective and professional working relationships with internal and external stakeholders and partners.  Communicate effectively with members and providers orally and in writing.
  6. Assist in gathering and processing data for internal required reports and analysis.
  7. Attend and actively participate in daily, weekly, and monthly departmental meetings, in-services, training and coaching sessions.
  8. Perform other duties as required or assigned.
  9. If assigned to Utilization Management, answer inbound UM telephone queue calls timely and work directly with members and/or providers regarding inquiries involving authorizations, SCFHP program services and/or benefits.
  10. If assigned to Utilization Management, follow UM policies and processes for authorization requests, including but not limited to the management of incoming authorization requests received through fax, mail or telephone, conducting data entry into the authorization software application system and, notification of member and/or provider of determination in accordance with regulatory timeframes as assigned.
  11. If assigned to Utilization Management, identify authorization requests for line-of-business, urgency level, type of service, and assess for complete/incomplete record submission.
  12. If assigned to Utilization Management, facilitate processing of Authorization Determination letters including approval, denial, delay and modify notifications to providers and members within regulatory processing timeframes.
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