Role Description The Utilization Management (UM) Health Services Coordinator provides operational and administrative support for Health Services and Utilization Management activities within the health plan. This role is responsible for: - Coordinating authorization intake and processing - Managing UM correspondence and reporting workflows - Supporting provider and member inquiries - Ensuring timely, accurate handling of utilization management requests in compliance with Medicare Advantage, CMS, HIPAA, and internal regulatory standards The UM Health Services Coordinator serves as a key liaison between: - Providers - Members - Clinical staff - Claims - Delegated entities This position requires strong organizational skills, attention to detail, regulatory awareness, and the ability to manage multiple priorities in a fast-paced managed care environment. Qualifications - Associate degree or equivalent combination of education and relevant experience - Minimum of 3–5 years of experience in managed care, health insurance, utilization management, medical office operations, claims, or provider services - Working knowledge of medical terminology, insurance terminology, CPT/HCPCS/ICD coding, and authorization processes - Experience handling high-volume administrative workflows with strong attention to accuracy and detail - Proficiency with Microsoft Office applications, including Excel, Outlook, and Word - Strong written and verbal communication skills - Ability to prioritize multiple assignments and meet regulatory and operational deadlines - Ability to work independently and collaboratively in a fast-paced environment - Strong customer service and problem-solving skills Requirements - Coordinate intake, entry, and processing of utilization management requests received via fax, portal, phone, and electronic submissions - Perform preliminary review of authorization requests for completeness, required documentation, eligibility verification, and benefit coverage - Route and escalate requests requiring clinical review to the appropriate nurse or medical director in accordance with UM guidelines and turnaround time requirements - Process expedited authorization requests and assist with required outreach and documentation - Support denial and modification workflows, including preparation, distribution, and documentation of adverse determination notices - Manage additional information requests for incomplete authorization submissions and follow up with providers as needed - Assist with out-of-network (OON) provider searches, wrap network verification, carve-out determinations, and Letters of Agreement (LOAs) - Coordinate retroactive review and authorization-related claims resolution activities with claims and clinical teams - Generate, distribute, fax, upload, and maintain authorization-related correspondence, letter logs, and required UM reports - Monitor and manage daily letter reporting processes and ensure timely filing and tracking of documentation - Attach and maintain fax confirmations and supporting records in accordance with departmental procedures and audit standards - Maintain accurate records within health plan systems, databases, and tracking tools - Assist with member and provider loading, eligibility verification, and data maintenance activities - Respond professionally and accurately to provider, member, and internal staff inquiries regarding authorization status, eligibility, benefits, and UM processes - Answer inbound calls, manage voicemail queues, and respond to departmental email inquiries in a timely manner - Develop and maintain positive working relationships with provider offices, delegated entities, hospitals, and community partners - Provide operational support for pharmacy coordination, medical records requests, and other Health Services functions as assigned - Ensure compliance with CMS, Medicare Advantage, HIPAA, NCQA, and internal Aspire Health Plan policies and procedures - Maintain confidentiality of protected health information (PHI) and sensitive member data - Support audit readiness through accurate documentation, tracking, and adherence to turnaround time standards - Participate in process improvement initiatives to enhance operational efficiency, accuracy, and member/provider experience - Provide administrative and project support to Medical Management leadership and committees as assigned - Assist with departmental projects, workflow updates, and cross-functional operational initiatives - Perform additional duties and responsibilities as assigned Benefits - Pay rate: 20.00-26.00 - Assigned Work Hours: 8AM-5PM PST - Position Type: Regular

• Manages all activities associated with inbound/outbound customer inquiries, including developing and implementing policies and procedures on the flow of information for clients assigned • Establishes and implements performance/service standards • Ensures productivity meets or exceeds service and quality standards • Establishes and maintains industry relations • Provides coaching and mentoring to Client Service Administrators • Owns the communication of requested process improvements from assigned customers • Escalates customers' issues to an appropriate level within the company as needed • Resolves customers' pain points of clients • Proactively looks for failure/potential failure, correcting them before the customers notice • Builds expertise in assigned verticals • Collaborates with internal departments, service branches, and technical and operations managers to facilitate the resolution of complex administrative and service issues to ensure customer satisfaction

• Manage an active caseload, processing various services through product delivery. • Correspond with customers in writing using correct templates and customer instructions. • Obtain necessary information and documentation to complete requested services. • Educate customers on available services and Medicare Secondary Payer Compliance. • Accurately review and enter data into the case management system according to requested services. • Prepare documents, templates, and other correspondence as needed using multiple software programs. • Review medical records to obtain rated ages. • Responsible for electronic file organization. • Receive and respond to telephone calls and emails, addressing customers' questions and concerns. • Collaborate with all teams to meet customer needs and internal service standards. • Work diligently to earn and maintain customer trust. • Escalate customer concerns to the Team Leader for review and resolution. • Review assigned exception reports. • Prepare a daily Work Condition Report. • Foster team cohesion by consistently demonstrating diplomatic, professional, and effective written and verbal communication. • Strictly adhere to company confidentiality policies and procedures, safeguarding sensitive information at all times. • Any other duties as may be assigned.

Role Description The Client Services Manager (CSM) is responsible for coordinating the cross-functional client team and is focused on achieving plans with clients, revenue retention, and client satisfaction and growth for the Prospective Payment PPM and CV products. The CSM serves as both internal and external client liaison accountable for triaging, managing, monitoring and support of client related activity. The CSM builds and sustains client relationships, achieves the client’s recognition of Cotiviti as a partner, and ensures client success with Cotiviti PPM/CV products through understanding client's needs and unique business situations, identifying solutions, proactively identifying potential issues that could impair success. Responsibilities - This position is client facing and requires a commitment to superior client service. - Serves as the primary client contact and trusted advisor for client operational representatives; establishes and cultivates relationships with client contacts to identify needs that result in expanded opportunities or solutions. - Collaborates with the Go-To-Market team on client strategic plan and leads tactical execution. - Promotes policy adoption and acceleration to increase client value through organization, communication, and project management within internal and external teams. - Identifies and communicates cross product opportunities. - Manages the operational implementation and execution of client payment policy decisions by collaborating with client operations managers across multiple departments, including Claims Operations, Provider Services, Appeals, Network Operations, Payment Integrity, IT, etc. - Coordinates and manages joint meetings with client and internal staff including scheduling, facilitation, meeting agenda and material preparation/coordination, meeting minutes/action item tracking, and meeting logistics. - Coordinates and manages client related internal meetings including scheduling, facilitation, meeting agenda and material preparation/coordination, meeting minutes/action item tracking, and meeting logistics. - Documents and distributes meeting minutes, action items and follows-up on action items to ensure satisfactory and timely completion. - Posts and maintains accurate, up-to-date client documentation in Cotiviti’s library. - Manages the internal and external aspects of all client initiatives and joint projects to ensure objectives are met and the team is progressing toward goals. - Monitors program performance, analyzes monthly performance reports, and drafts observations providing insight on trends for client consumption. - Identifies and performs root cause analysis to make recommendations and develops and executes on action plans to remedy interface related issues and unintended operational results to optimize program performance and consistency. - Provides client testing support to ensure success with all operational and policy aspects of initiatives. - Maintains escalation plans and monitors file processing statistics to minimize missed policy opportunity. - Proactively provides or coordinates production reporting, as necessary, to provide insight, and identify trends and data anomalies. - Ensures client success with Cotiviti customer service tools: administer user accounts to ensure data accuracy, monitor and manage user access and usage, and identify gaps. - Identifies client education needs and develop and deliver client training programs for implementing and active clients. - Manages all client inquiries, ensuring entry into the appropriate application and ensures timely execution of resolution. - Ensures understanding of client intent and triages appropriately. - Actively participates as an operational SME in department and corporate projects, as needed. - Travel requirement up to 20%. - Complete all responsibilities as outlined in the annual performance review and/or goal setting. - Complete all special projects and other duties as assigned. - Must be able to perform duties with or without reasonable accommodation. Qualifications - Bachelor’s Degree or higher (preferred), or equivalent experience, required. - Knowledge of CMS guidelines and other regulatory compliance guidelines and mandates, and medical payment policy. - Professional coder certification (CPC, CPC-A, CCA, CCS or CCS-P, RHIT or RHIA) certification not necessary but a plus. - 4+ years of related healthcare experience with strong knowledge of health plan operations and claims lifecycle. - 4+ years of experience in client relationship management or consulting experience, interacting with various roles and levels, with a strong focus on the healthcare setting. - 4+ years of project or team management experience, including meeting facilitation and follow-through on deliverables. - Highly proficient in MS Office Suite: Excel, Word and PowerPoint. - Excellent written and verbal communication and interpersonal skills. - Strong presentation skills. Prior experience delivering training classes is a plus. - Demonstrated success in developing strong, trust-based professional relationships with clients in multiple roles and levels. - Self-starter with the ability to work well independently and a track record of successful outcomes within a collaborative team environment or matrix structure. Requirements - Ability to work in a fast-paced environment, effectively organize, plan, prioritize and meet deadlines; producing high-quality, error-free deliverables. - Effective analytical and problem-solving skills and financial acumen. - Professional with ability to properly handle confidential information. - Ability to work with on-site and remote cross-functional product teams and customers. Working Conditions and Physical Requirements - This remote role can be located anywhere in the continental US. - Must have flexibility and willingness to participate in the work processes of an international organization, including conference calls scheduled to accommodate global time zones. - After hours and/or weekend work may be required where necessary for major deliverables/deadlines (not consistent). - Remaining in a stationary position, often standing or sitting for prolonged periods. - Repeating motions that may include the wrists, hands, and/or fingers. - Must be able to provide a dedicated, secure work area. - Must be able to provide high-speed internet access/connectivity and office setup and maintenance. - No adverse environmental conditions expected. Benefits - Base compensation ranges from $82,000 to $111,000 per year. - Cotiviti offers team members a competitive benefits package to address a wide range of personal and family needs, including: - Medical, dental, vision, disability, and life insurance coverage. - 401(k) savings plans. - Paid family leave. - 9 paid holidays per year. - 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti.