• Clinical Coordinator UM

    Job Locations US-RI-Smithfield
    Req No.
    Utilization Management
    Regular Full-Time
  • Overview

    Supports the day-to-day functions for Medical Management in order to facilitate efficient and effective department operations.  Facilitates all means of communication with members, providers, staff, and internal departments, and dedicated to continuous quality and process improvement of related processes.


    • Operates phone system for the Medical Management department efficiently and utilizing customer service principles; includes call triage, message center, and general inquiries, from providers and members
    • Responds to external and internal customer requests for information and clarification related to benefits, authorizations, and claims and initiates problem solving to ensure a smooth process for providers and members
    • Participates in outreach activities to providers and members to educate them regarding authorization and medical review processes, both internally and externally
    • Utilizes a broad knowledge of all lines of business to educate providers regarding authorization processes, procedures, and benefit criteria
    • Researches, reviews, responds to and triages incoming requests for authorization (phone, fax, mail) according to departmental procedure, including notification of hospitalizations, pre-certifications, ancillary services, out of area requests, conditional and non-covered benefits
    • Distributes work from fax machine and mail to appropriate clinical staff in accordance with regulatory requirements for processing
    • Identifies the need for medical review based upon knowledge of policy, benefit guidelines and provider network, and appropriately assigns to individual or team’s electronic “to do” list according to established guidelines
    • Provides accurate documentation of authorization data into the electronic data system, including pertinent information that impacts the payment of claims
    • Performs general office duties including typing, faxing, copying, mail management, filing, in adherence to departmental processes and regulatory guidelines
    • Communicates timely and effectively with Medical Management staff to facilitate the operational flow of the department
    • Recommends and facilitates implementation of department continuous quality and/or process improvement activities
    • Recommends and initiates activities that have a direct positive impact on provider or member satisfaction
    • Ability to train staff and produce documents needed for training
    • May conduct initial health assessments on new members, as needed
    • Other duties as assigned by Manager
    • Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and  the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.



    • A high school degree
    • Demonstrated written and verbal communication skills
    • Demonstrated organizational skills and ability to multi-task
    • Strong prioritization and time management skills
    • Excellent Customer Service orientation and phone etiquette
    • Strong interpersonal skills
    • Knowledge of medical terminology
    • Basic knowledge of Microsoft Word and Excel
    • Working knowledge of ICD-9 codes, HCPC and CPT procedure codes preferred
    • Related clinical administrative experience of at least 2 years, or minimum of 2 years experience as a Neighborhood Clinical Coordinator


    • Associates degree
    • Bilingual (English/Spanish)
    • Problem Solver

    Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.


    Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at recruiting@nhpri.org


    Neighborhood is an EOE M/F/D/V and an E-Verify Employer


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