Astrana Health

Technology-enabled platform delivering value-based care

Utilization Management Coordinator - Denials

Clinical Support & Patient AdministrationUpdated on Nov 13

Full-timeMonterey Park, CA, USA$21 - $26 /hr

About the Job

Requirements

A high school diploma or GED is required.
Knowledge of medical terminology, ICD-10, CPT, HCPCS, and RVS codes.
Proficiency in Microsoft Office and utilization management software such as InterQual or MCG.
Strong organizational, decision-making, and problem-solving skills.
Excellent verbal and written communication skills.
Ability to work effectively in a fast-paced team environment.
Minimum typing speed of 40 words per minute.
Open availability between Monday and Sunday, 8 a.m. to 8 p.m., with five shifts per week; weekends and holidays rotate among the team, and overtime may be required.

Responsibilities

Adhere to Astrana Health policies and applicable regulations, including Health Plan, DMHC, DHCS, CMS, and NCQA standards.
Process and attach deferrals, denials, and associated documentation accurately.
Review eligibility and verify benefits.
Manage provider and interdepartmental communications and provide customer service.
Accurately review and process daily deferrals and denials in accordance with IPA and health plan turnaround guidelines.
Review and process assigned deferrals or denials, including denial, modification, or carve-out, in compliance with policies, accreditation, and regulatory standards.
Verify member eligibility, benefits, and deferral or denial requirements.
Maintain accurate utilization management and denial system data and meet turnaround time standards.
Apply appropriate denial templates based on health plan, line of business, and threshold language.
Use the appropriate criteria according to hierarchy and line of business, using only approved standards.
Ensure denial language meets the appropriate reading ease and grade level for the line of business.
Ensure denial packets are complete before finalization, including the denial letter, authorization request, proof of receipt, clinical guidelines, and medical records.
Assist with Failed Fax Reports, Denial Inquiries, and Appeal/Grievance Inquiries.
Report activities or issues to the UM Denial Supervisor or Manager throughout the day.
Maintain integrity and confidentiality and comply with HIPAA standards.
Collaborate with the utilization management department and participate in quality improvement initiatives.
Perform other duties as required to support the department.

Desired Qualifications

At least one year of experience with a health plan or MSO.
Experience with health plans, managed care organizations, or hospital utilization management departments.
Familiarity with Health Plan, DMHC, DHCS, CMS, and NCQA requirements.
Ability to prioritize and delegate tasks effectively.

Astrana Health is seeking a dedicated Utilization Management (UM) Coordinator – Denials to join our Denial Department. This role ensures timely and accurate processing of all deferrals and denials in compliance with Astrana Health policies, NCQA standards, health plan requirements, and federal and state regulations. The UM Coordinator – Denials will review, monitor, and process prior authorization denials requests while maintaining strict adherence to regulatory and health plan guidelines.

This is a hybrid position out of our Monterey Park office that requires open availability between M-Su 8 A - 8 P. You would be scheduled for 5 shifts per week, weekends and holidays are rotated amongst the team, and there is overtime in this position. We are seeking candidates who are flexible and interested in working additional hours, including overtime. Overtime need is determined each day based on volume.

Our Values:

Put Patients First
Empower Entrepreneurial Provider and Care Teams
Operate with Integrity & Excellence
Be Innovative
Work As One Team

Adhere to Astrana Health policies and all applicable regulations, including Health Plan, DMHC, DHCS, CMS, and NCQA standards.
Process and attach deferrals, denials, and associated documentation accurately.
Review eligibility and benefits verification.
Manage provider and interdepartmental communications, delivering excellent customer service.
Accurately review and process daily deferrals and denials in accordance with IPA and health plan turnaround guidelines.
Review and process assigned deferrals or denials (e.g., denial, modify, carve-out) in compliance with policies, accreditation, and regulatory standards.
Verify member eligibility, benefits, and deferral/denial requirements.
Maintain accurate UM/Denial system data and meet turnaround time standards.
Apply appropriate denial templates based on Health Plan, Line of Business (LOB), and threshold language.
Ensure correct criteria are used according to hierarchy and LOB, utilizing only approved standards.
Verify that denial verbiage is written at the appropriate reading ease and grade level based on LOB.
Ensure denial packets are complete before finalization, including denial letter, authorization request, proof of receipt, clinical guidelines, and medical records.
Assist with Failed Fax Reports, Denial Inquiries, and Appeal/Grievance Inquiries.
Report activities or issues to the UM Denial Supervisor/Manager throughout the day
Maintain a high level of integrity and confidentiality, ensuring compliance with HIPAA standards.
Collaborate with UM department and participate in quality improvement initiatives.
Perform other duties as required to support the department.

High school diploma or GED required.
Knowledge of medical terminology, ICD-10, CPT, HCPCS, and RVS codes.
Proficient in Microsoft Office and UM software (e.g., InterQual, MCG).
Strong organizational, decision-making, and problem-solving skills.
Excellent verbal and written communication.
Able to work effectively in a fast-paced, team environment.
Minimum typing speed of 40 wpm.
Preferred:
- At least 1 year with a Health Plan or MSO.
- Experience with health plans, managed care organizations, or hospital UM departments
- Familiarity with Health Plan, DMHC, DHCS, CMS, and NCQA requirements.
- Ability to prioritize and delegate tasks effectively.

About the Company

Astrana Health

Technology-enabled platform delivering value-based care

Astrana Health runs a physician-focused, technology-enabled care platform that supports providers in delivering proactive, preventive, value-based care. Its end-to-end system coordinates care across affiliated networks, a management services organization, and primary, specialty, and ancillary clinics to help more than 20,000 providers and over 1.6 million Americans in value-based arrangements. How it works: the proprietary platform connects clinicians, patients, and care settings, enabling proactive care planning, care coordination, and efficient delivery of services in primary and specialty care. The company differentiates itself by combining a large provider network, an MSO, and clinics with a single tech platform to scale value-based care and improve patient experiences and outcomes rather than relying on fragmented, fee-for-service models. Its goal is to create a healthcare system that delivers better care, better experiences, and better outcomes for all.

Company size: 501-1,000
Company stage: Not listed
Total funding: Not listed
Headquarters: Alhambra, CA
Founded: Not listed

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