UM/QI Coordinator

Description

Verda Healthcare, Inc. is a Medicare Advantage Prescriptions Drug Plan (MAPD) organization committed to the idea that healthcare should be easily and equitably accessed by all, currently available in Texas and Arizona. Our mission is to ensure that underserved communities have access to health and wellness services, and receive the support needed to live a healthy life that is free of worry and full of joy. We are looking for a UM/QI Coordinator to join our growing company with many internal opportunities.

Are you ready to join a company that is changing the face of health care across the nation? Verda Healthcare, Inc. is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity.

Align your career goals with Verda Healthcare, Inc. and we will support you all the way.

Position Overview

Verda Healthcare is seeking an organized, detail-oriented Utilization Management (UM), Case Management (CM), and UM Operations Coordinator to join the UM/QI team. The Coordinator will support daily UM and CM operations, including census and admission management, outpatient authorization requests, inpatient notifications, medical record retrieval, discharge and transition-of-care activities, member outreach, and analytical data collection.

This role will work closely with the UM/CM Supervisors, Director, and Chief Medical Officer (CMO) of the Medical Management team to ensure timely processing, accurate documentation, effective communication, and efficient coordination of services.

Reports to: UM Supervisor

Essential Functions

Support the UM/CM/QI teams in processing authorization requests, referrals, inpatient notifications, transitions of care, member resources, and data collection activities.

Communicate with contracted providers, facilities, members, and internal departments to support UM/CM/QI workflows and obtain required information.

Receive and process service requests submitted through fax, email, provider portals, and other designated channels within established timeframes.

Prepare and process provider and member correspondence, including Letters of Agreement, approvals, denials, and other UM-related notifications.

Responsibilities:

• Process and coordinate prior authorization, referral, and inpatient notification requests; monitor status, route cases appropriately, follow up on outstanding information, and ensure timely completion.
• Respond to providers, vendors, facilities, and IPAs regarding authorization requests, status inquiries, documentation, and other UM-related needs.
• Request, retrieve, attach, and maintain medical records and supporting documentation for authorization and case management cases.
• Enter and update referral and authorization requests in the appropriate systems.
• Monitor and route phone calls, voicemails, emails, faxes, and mail; assist with provider and facility correspondence as needed.
• Conduct member outreach for case management programs to identify care coordination needs and connect members with appropriate healthcare services, community resources, education, and support.
• Provide administrative and operational support to UM, CM, and QI departments, including maintaining reports, logs, tracking tools, member records, and supporting data collection and analysis.
• Collaborate with internal departments and external providers to resolve authorization, documentation, and care coordination issues.
• Participate in quality and process improvement initiatives and provide general support to the UM department.

Verda cares deeply about the future, growth, and well-being of its employees. Join our team today!

Job Type: Full-time employment
Location: Huntington Beach, CA

Compensation Range:

$20 - 25 hourly

Actual compensation offered will be determined based on experience, qualifications, skills, internal equity (if available), and geographic location. This position may also be eligible for performance-based incentive compensation and benefits.

Benefits:

• 401(k)
• Paid time off (vacation, holiday, sick leave)
• Health insurance 
• Dental Insurance
• Vision insurance 
• Life insurance

Schedule:

• Full-time onsite (100% in-office)
• Hours of operations: 9am – 6pm
• Standard business hours Monday to Friday/weekends as needed
• Occasional travel may be required for meetings and training sessions.

Ability to commute/relocate:

• Reliably commute to the required office location, or planning to relocate before starting work.

PHYSICAL DEMANDS

Regularly sit/walk at a workstation in an office or cubicle setting. Must occasionally lift and/or move up to 25-50 pounds.

*Other duties may be assigned in support of departmental goals.

Requirements

Minimum Qualifications 

• 2 years of experienced in managed care with a health plan or IPA
• Good verbal and written communication skills.
• Working knowledge of Microsoft Word, Excel, and Outlook.

Professional Competencies

• High school diploma or general education degree (GED); with one to three months related experience and/or training; or equivalent combination of education and experience.