Job Duties

• Manage intake of provider requests for medical necessity determinations, through various modes of submission include but not limited to, secure fax, e-form or telephonic requests.

• Create UM review requests in accordance with Customer’s UM policies and procedures and documentation guideline.

• Provide current review status updates to requesting provider offices or receipt confirmations. 

• Provide information regarding clinical information requirements, additional clinical information requests and education on Customer’s UM processes and requirements to providers.

• Provide support to the UM nurses as needed to complete their clinical review requirements.

• Participate in department meetings, training and audit activities equal to Customer’s employees. 

• Perform other duties as assigned by the UM nurses.

Role/Education Requirements

• Minimum of 2 years of recent health plan experience  

• High level of expertise in UM services 

• Experience with MediCal and LA County procedures and policies (preferred but not required)

• Experience with MCG Criteria (preferred but not required)

Role Details

• Job Type: Contract

• Pacific business hours, Monday through Friday

• Evenings, weekends or holiday coverage, as needed

• Work Location: Remote