Concurrent Review Coordinator

Company: San Francisco Health Plan
Location: San Francisco
Posted on: November 1, 2024

Job Description:

Responsibilities:

• Research utilization management requests using a variety of resources including SFHP evidence of coverage, policies and procedures, and electronic resources.
• Compile data for utilization management review and submit the data to the Concurrent Review nurse team for clinical decision-making.
• Maintain ongoing tracking and appropriate documentation to facilitate the determination process within the regulatory timeframes for standard and urgent authorization requests.
• Support discharge planning efforts for members requiring post discharge follow-up care through telephonic coordination with primary care providers.
• Answer questions and resolve issues pertaining to providers, office staff, and delegated groups about authorization requests and determinations.
• Respond to calls, emails, and other inquiries regarding the status of outstanding clinical requests and utilization management processes. Ensure the privacy and security of PHI (Protected Health Information) as outlined in SFHP's policies and procedures relating to HIPAA compliance.
• Maintain an accurate census of SFHP members.
• Work with providers to obtain accurate information regarding authorization requests.
• Ensure correspondence distribution compliance by working with designated clinicians to generate Notice of Action (NOA) letters for the requesting providers and members.
• Foster an environment that solicits and enlists diverse and inclusive perspectives and approaches to better serve our staff, our members, and our providers.Minimum Requirements:
• One year of experience in customer service, call center setting.
• A bachelor's degree in health, Social or Life Sciences, Business, or a related field, preferred, or equivalent work experience.
• Current California Medical Assistant Certification or California Pharmacy Technician License without restriction or equivalent experience in a health care field with familiarity with medical terminology and concepts, preferred.
• Experience with Medi-Cal or Department of Health Care Services regulations and standards preferred.
• Experience in an HMO or experience in a managed care setting preferred.What We Offer:
• Medical: You'll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP.
• Dental: You'll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage.
• Vision: Employee vision care coverage is available through Vision Service Plan (VSP).
• Retirement: Employer-matched CalPERS Pension and 401(a) plans, 457 Plan.
• Time off: 23 days of Paid Time Off (PTO) and 13 paid holidays.
• Professional development: Opportunities for tuition reimbursement, professional license/membership.About SFHP:Established in 1997, San Francisco Health Plan (SFHP) is an award-winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco County. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 175,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services.San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals and in which our people processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics.Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.San Francisco Health Plan is an E-Verify participating employer. Hiring priority will be given to candidates residing in the San Francisco Bay Area and California.
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Keywords: San Francisco Health Plan, Pleasanton , Concurrent Review Coordinator, Other , San Francisco, California