Role Insights
This role of Care Coordinator is considered an essential position within the organization and Care Management Department. This role is responsible for assisting in the provision of telephonic patient care under the guidelines of AMM and in collaboration with the Care Management Team. This individual must be positive, caring, and maintain a professional attitude. The goal is to always provide the best patient care possible.
The right candidate should have confidence in their abilities as a problem solver and have the poise to execute solutions in a timely fashion. You will be responsible for making calls to patients as well as providers throughout your day. Good time management is essential.
Primary Responsibilities
Processing all OnBase images for the CM departmentMaintain 20-50 cases per day average productionProcesses all Tracking and TPL cases Assist in working the Bed Days Audit Manager errorsCover other Inpatient coordinators when they are out Be familiar with the contents of AMM Policy and Procedures and laws and regulations relating to Coordinator’sMaintain patient safety and privacy. Confidentiality is core Be flexible, pleasant, and willing to help patients in any way neededKnow and follow Employee Handbook policies and proceduresUse ADP as per the AMM Policy and ProceduresParticipate in team meetingsInitiate Access program – Print list of calls for the day (Make sure all call dates have been updated before printing query). Proceed with daily phone calls as per list (call frequency determined by CM Manager or Designee), update and document all specifics on flow sheet and face sheet (including medications).Update access program daily with dates phoned, return phone call, next PCP appointment, last hospitalization, etc.Check fax machine periodically for hospital discharge papers.Complete HRA’s under the guidance of the Care Manager to assist with identifying problems and provide solutions to patients if able (i.e. schedule appointments, help arrange transportation, call in refills, etc.) Any clinical problems or concerns identified with patients based on phone call and/or record flow sheet notify Nurse for further follow-up and/or instructions. Coordinators are not allowed to assess clinical or instruct patients on disease processes. Coordinators may reinforce and support patient education programs.Check hospital log daily and place High Risk patients on the board, in the hospital log, and update as needed.Check your voice mail periodically throughout the day and promptly return patient phone calls. If the patient’s problems cannot be answered, let them know that a Nurse will follow-up and they will be contacted soon. All Coordinator’s charting is to be signed off by the Nurse. NO EXCEPTIONS!Be familiar with the contents of AMM Policy and Procedures and laws and regulations relating to Coordinator’s.Maintain patient safety and privacy. Confidentiality is core. Be flexible, pleasant and willing to help patients in any way needed.Participate in staff meetings.Required Skills and Abilities
One year’s experience in a physician office or clinic preferred or IPA/Group UM or CM department Coordinator preferred. But individuals with BA degree from recognized university will be considered and trained.Ability to communicate verbally and in writing through proper channels.Maintain patient confidentiality.Promote departmental and organizational goals.1+ year in medical or healthcare environment preferredHigh energy and goal orientatedProblem solving and time management skillsBrilliant verbal and written skillsProficient in Word, Outlook, ExcelPositive attitude with great interpersonal skillsOutstanding work ethic Ability to work Monday through Friday 8:00am – 5:00pmAMM BENEFITS
When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:
Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan.Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe.Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work.Career Development: Tuition reimbursement to support your education and growth.Team Fun: Paid company outings and lunches because we work hard, but we also know how to have fun! Read LessPOSITION SUMMARY
The Clinical Services Manager is responsible for overseeing daily operations related to Utilization Management (UM), Clinical Auditing, and quality improvement initiatives within the organization. This role provides operational and clinical leadership to ensure efficient authorization processes, compliance with CMS/DMHC/health plan requirements, audit readiness, and continuous improvement in clinical and operational performance.
The Clinical Services Manager collaborates closely with interdisciplinary departments including Case Management, Quality Management, Provider Relations, Claims, Compliance, and Information Technology to support organizational goals related to patient care, regulatory compliance, operational excellence, and value-based care initiatives.
Essential Duties and Responsibilities
Utilization Management Operations
Oversee daily UM operations including prior authorization review workflows, referral management, and turnaround time (TAT) compliance.Monitor authorization queues to ensure compliance with CMS, DMHC, NCQA, and health plan regulatory requirements.Assist with development, implementation, and monitoring of UM policies, procedures, and workflows.Ensure timely processing of standard, urgent, and expedited authorization requests.Collaborate with Medical Directors and providers regarding medical necessity criteria and escalation processes.Monitor operational performance metrics including TAT compliance, productivity, denial trends, and authorization accuracy.Identify workflow inefficiencies and implement process improvement initiatives to enhance operational performance.Participate in implementation and optimization of UM technologies, automation tools, and reporting systems.Clinical Audit and Compliance Oversight
Oversee internal clinical audit activities related to UM, quality, and documentation compliance.Conduct routine audits to ensure adherence to regulatory requirements, internal policies, and health plan standards.Monitor corrective action plans (CAPs) and support departments in remediation activities.Prepare for external audits including CMS, health plan, NCQA, and delegated entity audits.Analyze audit findings and develop action plans to improve compliance and operational outcomes.Ensure accurate and complete clinical documentation supporting authorization and quality initiatives.Track audit trends and provide leadership reports with recommendations for process improvements.Staff Leadership and Development
Supervise and support UM nurses, coordinators, clinical auditors, and support staff.Monitor staff productivity, quality performance, and adherence to departmental standards.Provide ongoing education, coaching, and mentorship to staff.Conduct staff meetings, performance evaluations, and competency assessments.Support recruitment, onboarding, and training of clinical operations staff.Foster a collaborative and accountable team environment focused on quality and service excellence.Regulatory and Quality Management
Maintain knowledge of CMS, DMHC, NCQA, HIPAA, and health plan regulatory requirements.Support organizational quality improvement and value-based care initiatives.Collaborate with Quality Management and Case Management teams to improve patient outcomes and reduce avoidable utilization.Assist with policy and procedure development and annual regulatory review updates.Ensure compliance with delegated agreements and health plan performance standards.Data Analysis and Reporting
Review and analyze operational, audit, and utilization data to identify trends and opportunities for improvement.Develop and present reports, dashboards, and operational summaries to leadership.Monitor key performance indicators (KPIs) related to UM operations, audit outcomes, and compliance measures.Collaborate with analytics and IT teams to improve reporting capabilities and operational visibility.Qualifications
Education
Registered Nurse (RN) required.Bachelor of Science in Nursing (BSN) required; Master’s degree preferred.Current unrestricted California RN license required.Experience
Minimum 5 years of experience in Utilization Management, Clinical Operations, Quality, or Managed Care.Minimum 2 years of leadership or supervisory experience preferred.Experience with delegated medical groups, IPA/MSO environment, or health plans preferred.Experience with CMS, DMHC, NCQA, and health plan audits strongly preferred.Knowledge and Skills
Strong understanding of utilization management processes and regulatory requirements.Knowledge of managed care operations, clinical auditing, and quality improvement methodologies.Ability to analyze data and identify operational improvement opportunities.Strong leadership, organizational, and communication skills.Experience with UM platforms and electronic medical record systems preferred.Proficiency in Microsoft Office applications including Excel, Word, and PowerPoint.Physical Requirements
Prolonged periods of sitting and computer use.Ability to attend meetings and training sessions as required.Work Environment
Hybrid or office-based work environment depending on organizational needs.Fast-paced managed care and healthcare operations environment require multitasking and prioritization.AMM BENEFITS
When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:
Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan.Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe.Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work.Career Development: Tuition reimbursement to support your education and growth.Team Fun: Paid company outings and lunches because we work hard, but we also know how to have fun!Join AMM and experience a workplace where your health, growth, and happiness comes first!
Read LessPosition Summary
The Provider Configuration Supervisor is responsible for leading and overseeing all day-to-day provider and contract configuration activities within the claims adjudication system (EZCAP) for a fully delegated IPA/MSO operating under Full-Risk Medicare Advantage and Value-Based Care contracts.
This role ensures that providers, facilities, contracts, fee schedules, DOFRs (Delegated Organization Financial Responsibility), benefit configurations, and claims payment rules are configured accurately, timely, and in alignment with executed contracts, delegation agreements, and financial models. The Supervisor leads configuration analysts, enforces configuration standards, mitigates downstream claims risk, and ensures claims are clean, payable, and audit-defensible.
This is a mission-critical role: configuration errors directly result in incorrect provider payments, financial leakage, disputes, regulatory exposure, and provider dissatisfaction.
Core Accountability
Own the integrity, accuracy, and operational readiness of all provider and contract configuration within EZCAP to support clean claims adjudication under full-risk, delegated value-based contracts.
Key Responsibilities
1. Claims System Configuration Leadership (EZCAP)
Lead and supervise all provider, contract, and financial configuration activities within EZCAP.Ensure accurate setup and maintenance of:Providers (PCPs, Specialists, Facilities, Ancillaries)Provider hierarchies and affiliations (TIN, billing NPI, rendering NPI)Payor contracts and sub-contractsDOFRs (Delegated Organization Financial Responsibility)Provider Fee Schedules / Fee SetsCapitation arrangementsRisk pools, withholds, and bonus configurationsGlobal and partial delegation logicOwn configuration logic that determines who pays whom, how much, and under what rules.2. DOFR & Financial Responsibility Configuration
Configure and maintain DOFR structures reflecting:IPA vs Health Plan responsibilityPCP vs Specialist responsibilityIn-network vs out-of-network scenariosFacility vs professional claim logicEnsure DOFR logic aligns with:Delegation agreementsHealth plan contractsProvider contractsInternal financial models and actuarial assumptionsPartner with Finance and Actuarial teams to validate financial accuracy.3. Provider Fee Set & Contract Configuration
Oversee configuration of:Fee-for-service schedulesCase ratesPercent-of-charge modelsFlat fee arrangementsCustom carve-outsEnsure fee sets align precisely with executed provider contracts and amendments.Manage retroactive configuration changes with appropriate impact analysis and documentation.4. Team Leadership & Supervision
Supervise configuration analysts and specialists including:Work assignment and prioritizationTraining and onboardingQuality control and peer reviewPerformance managementEstablish configuration standards, SOPs, and naming conventions.Serve as escalation point for complex configuration scenarios and claims issues.5. Cross-Functional Coordination
Partner closely with:Credentialing (provider readiness)Contracting (interpretation of provider and payor contracts)Claims Operations (claims outcomes and issue resolution)Finance / Actuarial (payment accuracy and financial modeling)Provider Disputes (root cause resolution)Compliance (audit and delegation oversight)Translate contract language into executable system logic.6. Claims Readiness & Issue Resolution
Support claims production by ensuring configuration is:Complete prior to provider go-liveTested and validatedParticipate in claims triage for:UnderpaymentsOverpaymentsMisrouting of financial responsibilityPerform root-cause analysis of configuration-driven claims defects and implement corrective actions.7. Audit, Compliance & Delegation Readiness
Ensure configuration is audit-defensible for:Health plan delegation auditsInternal compliance reviewsCMS or regulatory inquiriesMaintain documentation for configuration decisions, overrides, and exceptions.Support Corrective Action Plans (CAPs) related to configuration findings.8. Change Management & Configuration Governance
Establish and enforce configuration change control processes.Review and approve:New provider buildsContract amendmentsRetroactive configuration changesMaintain configuration logs and version tracking.Ensure changes are communicated to downstream teams (claims, finance, provider relations).9. Reporting & Performance Oversight
Track and report configuration KPIs including:Provider build turnaround timeContract configuration cycle timeConfiguration defect rateClaims rework attributable to configurationProvide regular operational updates to the Senior Director of MSO Operations.Qualifications
Education
Bachelor’s degree in Healthcare Administration, Business, Finance, Information Systems, or related field preferred.Equivalent experience in delegated claims configuration accepted.Experience
6+ years of healthcare claims configuration experience in an IPA, MSO, or health plan.3+ years of hands-on EZCAP configuration experience required.2+ years of supervisory or lead experience strongly preferred.Deep experience in delegated, full-risk Medicare Advantage environments required.Proven experience configuring DOFRs, provider fee sets, and complex payment logic.Technical Expertise
Advanced EZCAP configuration knowledge:Provider buildsContract loadingDOFR logicFee schedulesStrong understanding of:Medicare Advantage delegation modelsClaims adjudication workflowsProvider payment methodologiesAdvanced Excel and analytical skills.Core Competencies
Exceptional attention to detailStrong systems and financial logic thinkingAbility to interpret contracts into executable system rulesLeadership and coaching capabilityHigh accountability and ownership mindsetStrong cross-functional communicationComfort operating in high-risk, audit-exposed environmentsKey Performance Indicators (KPIs)
Claims paid correctly on first passConfiguration error rateProvider build and contract setup turnaround timeReduction in configuration-related disputesAudit findings related to configurationTeam productivity and quality metricsAMM BENEFITS
When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:
Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan.Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe.Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work.Career Development: Tuition reimbursement to support your education and growth. Read LessPosition Summary
The Utilization Management (UM) Coordinator is responsible for coordinating prior authorization requests, processing referrals, documenting case activity, and supporting timely utilization review activities using the EZCAP Authorization System. The coordinator ensures compliance with CMS, DHCS, NCQA, and contracted health plan requirements while maintaining excellent customer service to providers, members, and internal departments.
The UM Coordinator serves as the first point of contact for authorization requests and works closely with nurses, medical directors, case managers, provider offices, and health plans to ensure timely and accurate processing of requests.
Essential Duties and Responsibilities
Authorization Management
Receive and process prior authorization requests through EZCAP. Verify member eligibility and health plan benefits. Verify provider participation and network status. Determine whether requests qualify for auto-approval. Create new authorization records in EZCAP. Enter accurate clinical and demographic information. Assign requests to the appropriate review queue. Prioritize urgent and expedited requests according to CMS requirements. Maintain authorization documentation throughout the review process. Process duplicate and corrected authorization requests.EZCAP Responsibilities
Create and update authorization cases. Document all provider communications. Upload supporting medical records. Scan and attach incoming documentation. Monitor pending authorization queues. Update authorization status throughout the review process. Route cases to UM Nurses and Medical Directors. Complete authorization closure after determination. Document letter mailing information. Verify authorization history.Provider Communication
Receive incoming provider telephone calls. Respond to fax and portal authorization requests. Obtain missing clinical documentation. Notify providers of additional information requests. Communicate authorization determinations. Escalate clinical questions to UM Nurses. Coordinate with provider offices regarding duplicate requests.Documentation
Accurately document:
Date and time of request Source of request Clinical information received Carve-out determination source Communication attempts Fax confirmations Telephone conversations Medical record receipt Provider follow-up Authorization status changesRegulatory Compliance
Maintain compliance with:
CMS Medicare Advantage regulations NCQA Utilization Management Standards DHCS Managed Care requirements Knox-Keene Act requirements Health plan contractual requirements Organization UM Policies and Procedures HIPAA Privacy and Security requirementsTurnaround Time (TAT) Monitoring
Monitor authorization turnaround times including:
Urgent requests Standard requests Additional information requests Extension notifications Pending authorizations Escalations approaching regulatory deadlinesQuality Responsibilities
Maintain complete authorization documentation. Follow departmental workflows. Meet production standards. Meet quality standards. Participate in internal audits. Correct identified documentation errors. Attend required training sessions. Assist with audit preparation.Daily Responsibilities
Review incoming authorization queue. Process fax requests. Process portal requests. Monitor urgent authorization requests. Follow up on pending cases. Upload clinical documentation. Document provider communication. Monitor worklists. Assist nurses with non-clinical tasks. Complete assigned production goals.Required Knowledge
Knowledge of:
Medical terminology ICD-10 diagnosis coding CPT/HCPCS procedure coding Prior authorization processes Medicare Advantage Managed Care operations HIPAA regulations CMS regulations NCQA standardsKnowledge of EZCAP preferred.
Required Skills
Excellent communication skills Strong organizational skills Time management Attention to detail Data entry accuracy Customer service Critical thinking Multitasking Problem solving Ability to prioritize urgent workMinimum Qualifications
Education
High School Diploma or GED required Associate degree preferredExperience
Minimum 1 year in healthcare Prior authorization experience preferred Managed care experience preferred Medical office experience preferred Health plan experience preferredComputer Skills
Experience with:
EZCAP Authorization System (preferred) Microsoft Outlook Microsoft Word Microsoft Excel Adobe Acrobat Electronic Fax Systems Electronic Health Records (EHR) Health Plan Provider PortalsPerformance Expectations
The UM Coordinator is expected to:
Meet departmental productivity goals. Maintain a quality score of 95% or higher. Process authorizations within regulatory turnaround times. Accurately document all authorization activities. Follow all departmental policies and workflows. Maintain confidentiality of Protected Health Information (PHI). Demonstrate professionalism with providers, members, and coworkers.AMM BENEFITS
When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:
Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan.Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe.Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work.Career Development: Tuition reimbursement to support your education and growth.Team Fun: Paid company outings and lunches because we work hard, but we also know how to have fun!Position Overview
We are seeking a highly technical, hands-on operational executive to serve as our Senior Director of MSO – Claims Operations & Provider Configuration. This position requires candidates to be based in Southern California.
This role requires a true Subject Matter Expert (SME) with deep, end-to-end expertise in claims operations within a fully delegated, full-risk Medicare Advantage environment. Direct, hands-on EZCAP experience is required.
This is not a high-level oversight position. The ideal candidate can speak in detail about adjudication logic, denial trends, provider configuration dependencies, and the operational issues they have personally resolved. This leader will own claims accuracy, configuration integrity, financial alignment, and measurable KPI performance across the MSO.
Key Responsibilities
End-to-End Claims Operations Ownership
Oversee the full claims lifecycle: intake, validation, adjudication, pricing, payment, adjustments, reprocessing, and reportingEnsure high first-pass adjudication rates and CMS-compliant turnaround timesMonitor denial trends and implement structured root cause corrective actionsServe as executive escalation point for complex claims and systemic issuesAlign claims operations with capitation models, IBNR, MLR, and risk pool performanceProvider Configuration & EZCAP Governance
Own provider configuration within EZCAP, including:DemographicsContract termsFee schedulesRisk arrangementsDelegation indicatorsEffective dates and terminationsEstablish configuration QA, validation, and change control governancePrevent mispricing, claims leakage, and downstream financial exposureEnsure system integrity across payor transitions, growth, and new market expansionPerformance Management & Operational Improvement
Improve measurable KPIs including:First-pass adjudication rateClaims accuracy rateTurnaround time (clean vs. non-clean)Rework percentageConfiguration error rateConduct root cause analysis on systemic operational issuesDesign and operationalize scalable, sustainable solutionsBuild dashboards and performance reporting for executive leadershipFinancial & Regulatory Stewardship
Ensure claims payments align with contract terms and value-based arrangementsMitigate overpayment, underpayment, and compliance riskLead audit readiness for CMS and health plan delegation oversightPartner with Finance and Actuarial on trend analysis and cost variance driversLeadership & Team Development
Lead managers and SMEs across claims and configuration teamsBuild a metrics-driven, high-accountability cultureCoach leaders on technical problem-solving and escalation managementEnsure operational readiness for audits, system upgrades, and organizational growthRequired Qualifications
Must be based in Southern California10+ years of healthcare claims operations experience5+ years in senior leadership managing managers and complex teamsDirect, hands-on EZCAP experience (required)Demonstrated expertise in:Claims adjudication logicProvider configuration and fee schedulesDelegated Medicare Advantage modelsCMS regulatory requirementsProven experience in a fully delegated, full-risk Medicare Advantage environmentStrong root cause analysis and process optimization backgroundDocumented success improving claims KPIs and reducing operational leakagePreferred Qualifications
Master’s degree (MBA, MHA, or related field)Multi-state IPA/MSO experienceExperience supporting rapid growth, new market expansion, or M&A integrationsBackground in operational automation or system optimization initiativesCore Competencies
Deep technical and operational expertise (not surface-level oversight)Financial and analytical acumenStrong executive judgment and escalation managementAbility to translate complexity into scalable executionCalm, decisive leadership under pressureAMM BENEFITS
When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:
Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan.Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe.Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work.Career Development: Tuition reimbursement to support your education and growth. Read Less