Shift Timings:<\/span><\/b>
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\u2022 Night Shift: 21:00 \u2013 06:00 IST (subject to change as per business requirement)<\/span><\/span>
<\/span>\u2022 5 days working<\/span><\/span>
<\/span>\u2022 365\-day operational process with staggered week\-offs<\/span><\/span>
<\/span>\u2022 Weekend/rotational support based on client requirements<\/span><\/span><\/p>

Job Summary:<\/span><\/b>
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The Utilization Management (UM) Coordinator is responsible for performing medical data entry tasks related to claims processing. This role involves verifying member eligibility, reviewing insurance details, and ensuring healthcare services are appropriately authorized. The position requires working through online portals and interacting with payers and providers via phone.<\/span>
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<\/span>The candidate must demonstrate a strong commitment to HIPAA compliance, ensuring the confidentiality, integrity, and security of all patient health information at all times.<\/span>
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<\/span>The ideal candidate is detail\-oriented, motivated, and committed to supporting accurate healthcare service coordination and enhancing patient care outcomes.<\/span><\/p>

Key Responsibilities:<\/span><\/b>
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· <\/span><\/span><\/span>Perform data entry tasks related to utilization management and claims processing with high accuracy.<\/span>
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· <\/span><\/span><\/span>Verify member eligibility and review insurance details using payer portals or through telephonic communication.<\/span>
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· <\/span><\/span><\/span>Ensure healthcare services meet medical necessity criteria and are appropriately documented.<\/span>
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· <\/span><\/span><\/span>Input clinical and administrative data into healthcare systems, ensuring completeness and accuracy.<\/span>
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· <\/span><\/span><\/span>Maintain strict adherence to HIPAA guidelines by ensuring confidentiality, integrity, and security of all patient health information.<\/span>
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· <\/span><\/span><\/span>Handle sensitive patient data responsibly and comply with all privacy and data protection regulations.<\/span>
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· <\/span><\/span><\/span>Adhere strictly to federal, state, and organizational guidelines.<\/span>
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· <\/span><\/span><\/span>Collaborate with healthcare providers and Medical Directors to review clinical information.<\/span>
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· <\/span><\/span><\/span>Facilitate prior authorizations, case conferences, and peer\-to\-peer reviews when required.<\/span>
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· <\/span><\/span><\/span>Provide clerical support to track patient progress and gather information for concurrent reviews.<\/span>
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· <\/span><\/span><\/span>Maintain accurate and organized records of all utilization management activities.<\/span>
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· <\/span><\/span><\/span>Handle administrative tasks such as phone inquiries, appointment coordination, and office support.<\/span>
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· <\/span><\/span><\/span>Ensure compliance with regulatory standards including Medicaid, Medicare, and Managed Care guidelines.<\/span>
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· <\/span><\/span><\/span>Participate in quality improvement initiatives and contribute to process enhancements.<\/span>
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· <\/span><\/span><\/span>Assist in monitoring and reporting utilization trends and outcomes.<\/span>
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· <\/span><\/span><\/span>Maintain professionalism and adhere to organizational policies and work standards.<\/span>
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Requirements<\/h3>

Required Skills & Competencies:<\/span><\/b>
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· <\/span><\/span><\/span>Strong knowledge of US Healthcare systems (Medicaid, Medicare, Commercial plans, Managed Care).<\/span>
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· <\/span><\/span><\/span>Basic understanding of medical terminology, anatomy, and physiology.<\/span>
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· <\/span><\/span><\/span>Familiarity with clinical guidelines (preferred).<\/span>
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· <\/span><\/span><\/span>Proficiency in MS Office applications, faxing, and VOIP systems.<\/span>
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· <\/span><\/span><\/span>Excellent communication skills (verbal and written).<\/span>
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· <\/span><\/span><\/span>Strong analytical and problem\-solving abilities.<\/span>
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· <\/span><\/span><\/span>Ability to work independently and within a team environment.<\/span>
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· <\/span><\/span><\/span>High level of accuracy and attention to detail.<\/span>
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Qualifications:<\/span><\/b>
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\u2022 Bachelor\u2019s Degree \u2013 preferably in Life Sciences<\/span><\/span>
<\/span>\u2022 Minimum 1 year of experience in US Healthcare processes (Utilization Management / Claims / Eligibility / Prior Authorization preferred)<\/span><\/span><\/p>

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