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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Utilization Management and data entry within a healthcare setting, ensuring compliance with regulatory standards and effective communication with providers and members. Proficient in managing authorizations, service requests, and member care coordination while maintaining high productivity and accuracy.
Highest-signal resume keywords
Utilization Management ExperienceData Entry Specialist ExperienceKnowledge of ICD 10 and CPT CodesBilingual (English/Spanish) SkillsManaged Care Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Data EntryUtilization ManagementICD 10 CodingCPT CodingMedical Management System ProficiencyEligibility VerificationService Request ApprovalMember Care CoordinationHEDIS Gap IdentificationDocumentation Compliance
Soft Skills
Customer Service SkillsProfessional CommunicationCollaborationAttention to DetailProblem-Solving
Tools & Technologies
Right Fax ServerEDI InterfaceFar ToolElectronic Medical RecordsWord Processing ApplicationsDatabase ApplicationsSpreadsheet Applications
Certifications & Qualifications
High School Diploma or GEDCalifornia Driver's License
Industry Keywords
HMOManaged CareHealthcare DeliveryAccreditation StandardsRegulatory Compliance
About the role
Key responsibilities & impact- Monitor the Right Fax server, EDI Interface, and medical management system intake to ensure face sheets are processed timely
- Ensure hard-copy and electronic face sheets are complete and accurate with current Member demographic information
- Review daily census reports to eliminate duplicates and other unnecessary admissions
- Cover Cisco ACD Queue telephone lines and phone queues
- Check eligibility and assign authorizations to the appropriate ITC nurse using the Far tool
- Attach reviews and orders into the medical management system for ITC nurse review
- Review and approve service requests within the ITC Coordinator scope under the Utilization Management Guide
- Obtain Member discharge dates from facilities via calls, electronic medical records, or memo submissions
- Meet productivity, accuracy, and timely-processing standards for inpatient authorizations, service requests, and discharges
- Assist referral processes by requesting additional medical information from providers by phone, fax, or email
- Set up hospital follow-up appointments and provide information to Members; document calls in the medical management system
- Ensure Members receive ordered Home Health and Durable Medical Equipment items, documenting calls
- Process and coordinate disenrollment and transportation as needed
- Answer Utilization Management Department calls professionally on behalf of the Inland Empire Health Plan
- Communicate with providers and facilities regarding authorizations, orders, and clinical reviews in consultation with the ITC Nurse
- Assist the ITC Nurse with care management coordination for Members with identified care management conditions
- Collaborate on Member care issues and consult with ITC Nurses or ITC management to ensure appropriate treatment plans are followed
- Assist with identifying HEDIS gaps and conducting Member outreach
- Ensure documentation complies with regulatory requirements and accreditation standards
- Support Management or the Inpatient Clinical Team as requested
- Attend scheduled meetings
- Promote a positive and collaborative working environment within the CM Team
Requirements
What you’ll need- Minimum of two (2) years of experience as a data entry specialist
- Data entry specialist experience preferably in an HMO or Managed Care setting
- Utilization Management experience preferred
- High School Diploma or GED required
- Bilingual (English/Spanish) written and verbal skills required for the applicable bilingual job code
- Must have a valid California Driver's License
- Requires knowledge of ICD 10 and CPT codes
- Knowledge of utilization management in a health care delivery setting preferred
- Managed Care or physician office experience required
- Skilled with computer applications, including word processing, database, and spreadsheets
- Good customer service skills
- Must pass a language proficiency assessment for the applicable bilingual job code
- Position requires completing necessary steps and receiving HR approval for telecommuting/hybrid work
Benefits
Comp & perks- Competitive salary
- Hybrid schedule
- State of the art fitness center on-site
- Medical Insurance with Dental and Vision
- Life, short-term, and long-term disability options
- Career advancement opportunities and professional development
- Wellness programs that promote a healthy work-life balance
- Flexible Spending Account – Health Care/Childcare
- CalPERS retirement
- 457(b) option with a contribution match
- Paid life insurance for employees
- Pet care insurance