UM Coordinator - Denials at Astrana Health in Monterey Park, CA

Summary: Astrana Health is seeking a dedicated Utilization Management (UM) Coordinator – Denials to join our Denial Department. This role ensures timely and accurate processing of all deferrals and denials in compliance with Astrana Health policies, NCQA standards, health plan requirements, and federal and state regulations.

Responsibilities:
- Adhere to Astrana Health policies and all applicable regulations, including Health Plan, DMHC, DHCS, CMS, and NCQA standards
- Process and attach deferrals, denials, and associated documentation accurately
- Review eligibility and benefits verification
- Manage provider and interdepartmental communications, delivering excellent customer service
- Accurately review and process daily deferrals and denials in accordance with IPA and health plan turnaround guidelines
- Review and process assigned deferrals or denials (e.g., denial, modify, carve-out) in compliance with policies, accreditation, and regulatory standards
- Verify member eligibility, benefits, and deferral/denial requirements
- Maintain accurate UM/Denial system data and meet turnaround time standards
- Apply appropriate denial templates based on Health Plan, Line of Business (LOB), and threshold language
- Ensure correct criteria are used according to hierarchy and LOB, utilizing only approved standards
- Verify that denial verbiage is written at the appropriate reading ease and grade level based on LOB
- Ensure denial packets are complete before finalization, including denial letter, authorization request, proof of receipt, clinical guidelines, and medical records
- Assist with Failed Fax Reports, Denial Inquiries, and Appeal/Grievance Inquiries
- Report activities or issues to the UM Denial Supervisor/Manager throughout the day
- Maintain a high level of integrity and confidentiality, ensuring compliance with HIPAA standards
- Collaborate with UM department and participate in quality improvement initiatives
- Perform other duties as required to support the department

Required Qualifications:
- High school diploma or GED required
- Knowledge of medical terminology, ICD-10, CPT, HCPCS, and RVS codes
- Proficient in Microsoft Office and UM software (e.g., InterQual, MCG)
- Strong organizational, decision-making, and problem-solving skills
- Excellent verbal and written communication
- Able to work effectively in a fast-paced, team environment
- Minimum typing speed of 40 wpm

Preferred Qualifications:
- At least 1 year with a Health Plan or MSO
- Experience with health plans, managed care organizations, or hospital UM departments
- Familiarity with Health Plan, DMHC, DHCS, CMS, and NCQA requirements
- Ability to prioritize and delegate tasks effectively

Required Skills: Medical Terminology, ICD-10, CPT, HCPCS, RVS Codes, Microsoft Office, InterQual, MCG, Health Plan Compliance, DMHC Regulations, DHCS Regulations, CMS Regulations, NCQA Standards, HIPAA Compliance, Typing Speed 40 wpm