You are applying for a position through Medix, a staffing agency. The actual posting represents a position at one of our clients.
Job Summary
Our client is seeking a Care Management Associate responsible for processing prior-authorizations, concurrent reviews, and retrospective requests. This role includes administrative triage, data integrity, and regulatory compliance to ensure efficient operations within the Utilization Management (UM) department.
Key Responsibilities
- UM Intake & Entry: Receive and process prior-authorizations, concurrent reviews, and retrospective requests from providers.
- Clinical Triage: Perform initial administrative triage by separating requests that meet "auto-approve" criteria from those requiring higher-level clinical review by an RN or Medical Director.
- Medical Necessity Support: Reach out to facilities and provider offices to collect clinical notes, lab results, or imaging required for the UM clinical team to make a determination.
- Regulatory Compliance: Monitor and manage the UM queue to ensure all requests are processed within state and federal mandated Turnaround Times (TAT).
- Notification Management: Issue formal UM determinations (Approvals, Pendings, or Denials) to members and providers via system-generated correspondence.
- Data Integrity: Ensure all UM cases are coded correctly with the appropriate ICD-10, CPT, and HCPCS modifiers to prevent downstream claims friction.
Qualifications
- Education: High School Diploma or GED.
- UM Knowledge: Solid understanding of the difference between Prior-Authorization, Concurrent Review, and Discharge Planning.
- Attention to Detail: Ability to distinguish between different lines of business (e.g., Medicaid vs. Medicare Advantage) and their specific UM rules.
Experience
- 1–3 years in a healthcare UM, Managed Care, or Health Insurance environment.
Skills
- Technical Knowledge: Familiarity with NCQA or URAC standards for Utilization Management.
- Medical Terminology: Strong grasp of medical language to accurately transcribe provider requests into the UM system.
- Problem Solving: Ability to identify "urgent" medical requests that require immediate escalation to prevent delays in patient care.
Additional Requirements
- Schedule: Full-time (40 hours/week), Monday–Friday, with occasional rotating coverage for weekend "urgent intake" queues.
Benefits
- Paid Sick Leave (Medix provides paid sick leave according to state and local sick leave ordinances).
- Health Benefits / Dental / Vision (Medix offers 6 different health plans: 3 Major Medical Plans, 2 Fixed Indemnity Plans (Standard and Preferred), and 1 Minimum Essential Coverage (MEC) Plan. Eligibility for health benefits is based on verifying that an average of 30 hours per week during the first 4 weeks of the work assignment has been met. If you meet eligibility requirements and take action to enroll, you will be covered no earlier than 60 days into your assignment, depending on plan selection(s)).
- 401k (Eligible on the first 401k open enrollment date following 6 consecutive months on assignment. 401k Open Enrollment dates are 1/1, 4/1, 7/1, and 10/1).
- Short Term Disability Insurance.
- Term Life Insurance Plan.
Required Employment / Compliance Language
Our client is an Equal Opportunity Employer and is committed to diversity and inclusion in the workforce. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability status, protected veteran status, or any other characteristic protected by law.
*We will consider for employment all qualified Applicants, including those with criminal histories, in a manner consistent with the requirements of applicable federal, state, and local laws, including the City of Los Angeles' Fair Chance Initiative for Hiring Ordinance (FCIHO), Los Angeles Fair Chance Ordinance for Employers (ULAC), The San Francisco Fair Chance Ordinance (FCO), and the California Fair Chance Act (CFCA).
Medix Overview:
With over 20 years of experience connecting organizations with highly qualified professionals, Medix is a leading provider of workforce solutions for clients and candidates across the healthcare, scientific, technology, and government industries. Through our core purpose of positively impacting lives, we’re dedicated to creating opportunities for job seekers at some of the nation's top companies. As an award-winning career partner, Medix is committed to helping talent find fulfilling and meaningful work because our mission is to help you achieve yours.
Any required state or Joint Commission training is compensated at the state or local minimum wage rate.
*As a job position within our Care Management division, a successful completion of a background check may be required as a condition of employment. This requirement is directly related to essential job functions including but not limited to: accessing financial and confidential information, access and handling of patient medical records, providing medical care inside a patient’s residential address, driving, prescription and other drug access and administration, and working with vulnerable populations, such as, minors, elderly and those with physical or mental disabilities. Due to these job duties, this position has a significant impact on the business operations and reputation, as well as the safety and well-being of individuals who may be cared for as part of the job position or who may interact with staff or clients.
