Under the supervision of the Supervisor of Physical Health Utilization Management, the Utilization Service Coordinator is responsible for all physical health components of Utilization Review for Colorado Access. Identifies members through the review process that are eligible for intensive case management. Makes referrals as appropriate to community resources and agencies. Works in collaboration with other teams within the Coordinated Clinical Services department to facilitate efficient administration of departmental policies and procedures. Responsible for applying criteria and/or guidelines specific to authorization reviews.
Responsible for all aspects (i.e. documentation, authorization letters, etc.) regarding authorizations, utilization management and coordination of inpatient acute care, sub-acute, outpatient care, rehabilitation services, and home health care for consumers accessing physical health and/or behavioral health benefits. Facilitates and coordinates discharge planning and works towards reduction of preventable hospital admissions, re-admissions, excessive therapies, DME, etc.
Interfaces with network providers regarding consumer service plans and care coordination. Participates in the evaluation and integration of wrap around services in relation to the overall service plan which may involve travel to attend meetings regarding consumer care or the system of care.
Works closely with the Supervisor of Behavioral Health Utilization Management to identify and solve problems related to providers, provider networks, access to and availability of services.
Supports quality improvement activities. Reports potential quality issues and concerns to the Medical Director and the Quality Management department.
Performs onsite and/or telephonic concurrent reviews of inpatient and outpatient episodes of care. Gathers pertinent clinical information and applies/interprets criteria to ensure medical necessity, covered benefits, participating providers and appropriate services. Refers cases not meeting approved criteria/guidelines to the Medical Director for determination.
Works closely with other teams within the Coordinated Clinical Services department to ensure that departmental goals are met.
Responsible for effective collaboration, communication and coordination among all responsible parties of an individual member's multidisciplinary health care team striving to eliminate fragmentation, duplication or gaps in treatment plans.
Understands, communicates and facilitates on behalf of the consumer, providers and other ancillary suppliers the complaint, grievance and appeal processes. Advises on the existing resources such as "Member's Handbook" and "Provider Manual".
Facilitates and engages in ongoing, real time, and comprehensive communications of their efforts, issues, progress, and barriers with other CCS Staff, Supervisors and Managers.
Due to the pandemic, our employees are temporarily working at home. We require our workforce to reside in Colorado and telecommute, which may require you to come into the office as we serve our local communities.
COMPENSATION & BENEFITS:
Compensation: $46,000.00 - $84,500.00 annually. Pay rate/salary to be commensurate with experience.
Benefits: In addition to being part of a mission driven organization that serves our community, eligible Colorado Access employees receive a generous benefits package, including:
Medical, Dental, & Vision starting the 1st day of the month following start date.
Supplemental insurance such as critical illness and accidental injury.
Healthcare and Dependent care flexible spending account options.
Employer Paid Basic Life Insurance and AD&D (employee, spouse and dependent).
Short-term and Long-term Disability Coverage.
Voluntary Life Insurance (employee, spouse, dependent).
Paid Time Off
Tuition Reimbursement (based on eligibility).
Annual bonus program (based on eligibility, requirements and performance).
Colorado Access is committed to providing equal opportunities to all people regardless of race, color, national origin, age, sex, genetic information, religion, pregnancy, disability, sexual orientation, veteran status or any other status protected by applicable law. We strive to maintain a work environment that is free from unlawful harassment and discrimination.
Education: Bachelor’s degree in nursing required.
Experience: Three years of clinical case management and healthcare experience in the physical or clinical setting required. Experience working with Managed Care, Medicaid and Medicare populations is preferred. Experience with concurrent review, quality improvement processes, ICD9, CPT4 and DRG coding preferred.
Knowledge, Skills, and Abilities: Knowledge of managed care and utilization management required. Demonstrates support for the company’s mission, vision and values. Position requires excellent written and verbal and written communication skills, strong organizational and time management skills, strong interpersonal skills and the ability to handle multiple priorities. Ability to work independently with minimal supervision. Ability to work effectively with Colorado Access staff, members, physician office staff and other providers. Requires basic computer knowledge with experience in Microsoft Word and Excel preferred. May be required to manage multiple priorities and projects with tight deadlines.
Licenses/Certifications: Active Colorado Nursing (i.e. RN, LPN). A valid driver's license and proof of current auto insurance will be required.
Colorado Access is a local, nonprofit health plan that serves more than one million members. The company’s members receive health care under Child Health Plan Plus (CHP+), and Health First Colorado (Colorado’s Medicaid Program) behavioral health, physical health, and long-term support programs. Colorado Access provides care coordination services and administers behavioral health and physical health benefits for two regions as part of the Regional Accountable Entity program through Health First Colorado.