Duties & Responsibilities: - 85% - Utilization Management Services Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department. Reviews requests for medical appropriateness by using established clinical protocols to determine the medical necessity of the request. Responsible for mailing rendered decision notifications to the provider and member, as applicable. Screens inpatient and outpatient requests for the Medical Director’s review, gathers pertinent medical information prior to submission to the Medical Director, follows up with the requester by communicating the Medical Director’s decision and documents follow-up in the utilization management system. Completes the required documentation for data entry into the utilization management system at the time of the telephone call or fax to include any authorization updates. Contacts the health networks and/or CalOptima Health Customer Service regarding health network enrollments. Identifies and reports any complaints to the immediate supervisor utilizing the call tracking system or through verbal communication if the issue is of an urgent nature. Refers cases of possible over/under utilization to the Medical Director for proper reporting. Completes care coordination activities as related to Transition Care Management (TCM) activities. Reviews International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and the existence of coverage specific to the line of business. - Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. - Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department. - Reviews requests for medical appropriateness by using established clinical protocols to determine the medical necessity of the request. - Responsible for mailing rendered decision notifications to the provider and member, as applicable. - Screens inpatient and outpatient requests for the Medical Director’s review, gathers pertinent medical information prior to submission to the Medical Director, follows up with the requester by communicating the Medical Director’s decision and documents follow-up in the utilization management system. - Completes the required documentation for data entry into the utilization management system at the time of the telephone call or fax to include any authorization updates. - Contacts the health networks and/or CalOptima Health Customer Service regarding health network enrollments. - Identifies and reports any complaints to the immediate supervisor utilizing the call tracking system or through verbal communication if the issue is of an urgent nature. - Refers cases of possible over/under utilization to the Medical Director for proper reporting. - Completes care coordination activities as related to Transition Care Management (TCM) activities. - Reviews International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and the existence of coverage specific to the line of business. - 10% - Administrative Support Assists manager with identifying areas of staff training needs and maintains current data resources. Complies with data tracking protocols. - Assists manager with identifying areas of staff training needs and maintains current data resources. - Complies with data tracking protocols. - 5% - Completes other projects and duties as assigned. Benefits At Amergis, we firmly believe that our employees are the heartbeat of our organization and we are happy to offer the following benefits: + Competitive pay & weekly paychecks + Health, dental, vision, and life insurance + 401(k) savings plan + Awards and recognition programs *Benefit eligibility is dependent on employment status. About Amergis Amergis, formerly known as Maxim Healthcare Staffing, has served our clients and communities by connecting people to the work that matters since 1988. We provide meaningful opportunities to our extensive network of healthcare and school-based professionals, ready to work in any hospital, government facility, or school. Through partnership and innovation, Amergis creates unmatched staffing experiences to deliver the best workforce solutions. Amergis is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected Veteran status, age, or any other characteristic protected by law.