Central Coast Hourly Range - $23.30 - $32.62
While candidates from anywhere in California are welcome to apply, there is a strong preference for those who reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties). This role may offer opportunities for remote work; however, familiarity with and proximity to our local customers is valued.
Job Summary
The D-SNP Clinical Support Associate – UM (CSA – UM) is assigned to the Utilization Management (UM) department and reports to the Associate Director, D-SNP Clinical Programs. The CSA–UM is not a licensed clinical position but requires knowledge of medical terminology and managed care processes (Medi-Cal and Medicare) to effectively support the UM team.
Duties and Responsibilities
Coordinate and support daily Utilization Management (UM) operations:
Accurately enter authorization requests and submitted documents into the authorization system.
Obtain all necessary documentation to process referrals to complete requests.
Verify eligibility and/or other payer sources.
Accurately enter diagnosis and procedure details (e.g., codes, service categories, CPT Codes, types, amounts, frequencies/volumes) as submitted by providers into the UM system as applicable.
Process authorization requests within established timeframes (CMS, DHCS, etc.); track and monitor timeliness of service authorization and referral requests.
Accurately prepare, edit, finalize, and distribute written determination notices for providers and members; retain/store documents related to authorization requests and determination notices.
Process limited authorization requests according to established guidelines.
As directed, process long-term care recertification requests.
As directed, process inpatient authorization requests.
Track and monitor the timeliness of requests; escalate delays when needed.
Adhere to authorization timelines set by CMS, DHCS, health plan operations and other governing agencies.
Adherent to protocols, policies, procedures, and performance standards.
Provide administrative and clerical support to UM staff:
Provide administrative support for department meetings, training sessions, and audits.
Respond to emails, phone calls, and other communications in a timely, professional, and courteous manner.
Participate in continuous improvement efforts for UM workflows and member/provider communication.
Attend company-wide and departmental meetings and training sessions on time and actively participate when appropriate.
Perform other duties as assigned.
Serve as a liaison between clinical reviewers, providers, members, and internal departments:
Promptly answer inbound calls from the Health Services phone queues and the unit phone queue.
Make outbound calls to providers, members, and CenCal Health staff regarding operational processes and the status of authorizations, additional documentation or UM processes.
Respond to inquiries about the authorization process and request status from providers, members, and staff from other departments.
Serve as a liaison between clinical reviewers and providers/members.
Communicate any conflicts or difficulties with members or providers to the immediate supervisor in a timely manner.
Collaborate and communicate with other Health Plan departments, including Member Services, Provider Services, Care Management and Claims.
Inform members and providers about the authorization and appeal processes.
Apply knowledge of medical terminology and managed care processes to support UM activities:
Maintain confidentiality and privacy of member information in accordance with HIPAA and applicable laws/regulations.
Ensure compliance with CMS, DHCS, and other regulatory bodies in the processing of requests.
Utilize understanding of medical terminology, coding, and managed care practices to support authorization processing. (Implied in tasks under Global Responsibility #1 but informed by this responsibility).
Participate in continuous learning and training to stay current with UM-related policies and terminology.
Knowledge / Skills / Abilities
Service Orientation & Cultural Sensitivity: Demonstrates courteous, respectful, and professional support when interacting with members, caregivers, providers, and colleagues. Effectively engages with individuals from diverse cultural, linguistic, and educational backgrounds.
Effective Communication: Communicates clearly and professionally in both verbal and written formats. Composes grammatically correct, concise messages and is able to explain utilization management (UM) processes and status updates to internal and external stakeholders.
Utilization Management Process Knowledge: Understands foundational UM workflows, including prior authorization and referral procedures, eligibility verification, and distinctions between standard and expedited processing timelines. Knows when to escalate or route requests to licensed clinical staff or medical directors, per established protocols.
Regulatory and Privacy Compliance: Maintains strict adherence to HIPAA and other applicable privacy laws. Complies with regulatory requirements and authorization timelines established by CMS, DHCS, and other governing agencies.
Documentation and Data Entry: Accurately enters and maintains complete and organized documentation for service requests in accordance with department standards and system protocols.
Medical Terminology and Code Recognition: Recognizes commonly used medical terms, diagnosis codes (ICD-10), and procedure codes (CPT/HCPCS) for the purpose of accurate data entry into the UM system. Note: This role does not perform coding.
Time Management and Prioritization: Effectively manages workload and competing priorities to meet turnaround times and regulatory deadlines. Demonstrates the ability to work efficiently in high-volume environments.
Attention to Detail and Accuracy: Consistently ensures accuracy in data entry, including member identifiers, dates of service, and clinical details. Identifies and addresses incomplete or missing documentation.
Teamwork and Interdepartmental Collaboration: Works cooperatively with UM clinical staff and collaborates across departments such as Member Services, Provider Services, and Claims to facilitate timely processing and resolution of requests.
Issue Identification and Escalation: Recognizes and promptly communicates service delivery challenges, member or provider concerns, or workflow barriers to supervisors or appropriate personnel, following established procedures.
Professionalism and Dependability: Demonstrates alignment with CenCal Health’s mission, policies, and performance expectations. Consistently attends required meetings, training sessions, and responds to communications in a timely manner.
Adaptability and Willingness to Learn: Responds positively to feedback and adapts to changes in department procedures, systems, or workflows. Demonstrates initiative in learning and applying new skills or updates.
Education and Experience
Associate’s degree in health sciences, health administration/management, business, or a related field or 2 years equivalent experience in lieu of a degree.
Must be able to type at a minimum speed of 35 words per minute.
Two (2) years of experience in a managed care, UM, or health plan environment or equivalent experience in a medical office, health plan, managed care organization, hospital, clinic, or similar healthcare setting.
Familiarity with Medi-Cal/Medicare basics and provider/member service workflows.
Bilingual in Spanish preferred.