UM Coordinator

Join VillageMD as a Coordinator, Utilization Management (Houston, Texas | Hybrid)

Join the frontlines of today's healthcare transformation

Why VillageMD?

At VillageMD, we're looking for a Coordinator, Utilization Management to help us transform the way primary care is delivered and how patients are served. As a national leader on the forefront of healthcare, we've partnered with many of today's best primary care physicians. We're equipping them with the latest digital tools. Empowering them with proven strategies and support. Inspiring them with better practices and consistent results.

We're creating care that's more accessible. Effective. Efficient. With solutions that are value-based, physician-driven and patient-centered. To accomplish this, we're looking for individuals who share our sense of excellence, are ready to embrace change, and never settle for the status quo. Individuals who have the confidence to lead but the humility to never stop learning.

Could this be you?

As an integral member of the VillageMD Team, Coordinator, Utilization Management is accountable for developing and implementing clinical documentation educational best practices across a quickly growing, primary care practice network.

As part of our clinical support team, you will be a key component in customer satisfaction and have a responsibility to make every contact informative, productive, and positive for our members and providers. 

How you can make a difference

• Providing excellent customer service to both providers and members by responding to and resolving incoming inquiries and requests
• Consistently meeting established productivity and quality standards while adhering to schedules and maintaining good attendance
• Receiving care coordination notifications for non-clinical assessment/intervention and provide appropriate triage
• Processing notifications for inpatient admissions, outpatient procedures, home health, DME, transition of care, and network gap issues
• Processing out-of-network requests for consideration of in-network level of benefits for physician specialty referrals
• Determining benefit coverage based on contracts
• Communicating benefit determinations to providers/members and processing letters within timeframes
• Ensuring potential member needs are identified and forwarded to the appropriate UM Care Manager for risk evaluation and refer to Population Health as relevant
• Verifying appropriate ICD-10 and CPT coding usage
• Assisting with processing of faxes and emails, including sending provider “fax forms” for certain clinical scenarios as designated
• Making outbound calls to contact providers, requesting clinical from provider as necessary
• Taking inbound calls to provide status of cases from providers
• Ensuring cases requiring Prior Authorization are “scrubbed” prior to sending to clinical reviewer, and include all necessary components
• Taking inbound calls from providers requesting a Peer-to-Peer discussion, preparing requests for Peer-to-Peer discussions with Medical Directors and assigning them in the UM platform
• Confirming urgent versus non-urgent requests
• Cooperating with all members of UM team to ensure compliance with standards and regulations
• Working with other departments to ensure appropriate handling of customer requests
• Handling provider/member requests for pre-service, concurrent and retrospective reviews
• Performing initial triage of case types
• Providing information on available services, and coordinating with nurses and medical directors on the review of requested services for health plan members
• Managing time-sensitive review requests and doing live outreach to providers
• Prioritizing and organizing work to meet deadlines while working with others as part of a team

Skills for success

• Using best knowledge and judgment to escalate complex problems to manager when necessary
• Proficiency utilizing electronic medical record and documentation programs
• Demonstrated experience with medical terminology and/or ICD-10 codes
• Prior member service or customer service telephone experience
• Experience working in the healthcare industry, hospital setting, physician's office or medical clinical setting
• Experience with Utilization Review and/or Prior Authorization, preferably within a managed care organization
• A low ego and humility; an ability to gain trust through good communication and doing what you say you will do

Experience to drive change

• High school diploma or GED required
• 2+ years of professional experience in a clerical or administrative support related role
• Excellent verbal and written communication skills, bilingual English/Spanish a plus
• Demonstrated ability to type 35 WPM or more
• Flexibility to work outside standard hours of operation due to changing business needs
• Working knowledge of MS Office including Word, Excel, and Outlook in a Windows based environment and an ability to quickly learn new systems

How you will thrive

In addition to competitive salaries, a 401k program with company match, bonus and a valuable health benefits package, VillageMD offers paid parental leave, pre-tax savings on commuter expenses, and generous paid time off. You work in a highly-collaborative, conscientious, forward-thinking environment that welcomes your experience and enables you to make a significant impact from Day 1.

Most importantly, you make a difference. You see a clear connection between your daily work on VillageMD products and services and the advancement of innovative solutions and improved quality of healthcare for providers and patients.

Our unique VillageMD culture – how inclusion and diversity make the difference

At VillageMD, we see diversity and inclusion as a source of strength in transforming healthcare. We believe building trust and innovation are best achieved through diverse perspectives. To us, acceptance and respect are rooted in an understanding that people do not experience things in the same way, including our healthcare system. Individuals seeking employment at VillageMD are considered without regard to race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status. 

Those seeking employment at VillageMD are considered without regard to race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status or disability status.

Explore your future with VillageMD today.