Utilization Management Coordinator I
PacificSource

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PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

The Utilization Management (UM) Coordinator I is fundamental to the utilization management team and receives, researches, and coordinates initial and follow-up action related to clinical documentation and requests from a variety of sources. Adheres to rigorous regulatory requirements, builds team collaboration, contributes to team improvements, and creates enhanced member and provider partner relationships.

Essential Responsibilities:

• High level - Adhere to dependability, member and provider focus, and all performance criteria as established by the department including: timeliness, production, and quality standards for all functions.
• Follow stringent guidelines to ensure all work meets PacificSource corporate standards for accuracy and compliance with federal, state, and national accreditation regulations.
• UM Process - Coordinate, create, and document UM cases in the electronic record by validating preauthorization requirements, utilizing a basic understanding of ICD, CPT and HCPCS codes, and including plan types, member benefits, eligibility, limitations, exclusions, and claims history.
• Assess accuracy of daily inpatient information from external systems and inpatient facilities, compile inpatient data, create inpatient events including diagnosis codes, and triage for review by UM and CM clinical staff.
• Collaborate with clinical staff by synchronizing information for utilization management, care management, prior authorization, inpatient stay, and retroactive claim reviews. Integrate medical records as required and document status of internal or external reviews in the medical record. Identify and promptly initiate corrective steps to resolve workflow issues.
• Administratively authorize services as directed by UM Leadership.
• Effectively manage an active telephonic queue by delivering excellent customer service to incoming caller and documenting HIPAA compliance. Provide information on prior authorization, referrals, inpatient admissions and stays, health-related information, determinations, claims review, and possess an understanding of when to forward members and providers to Appeals and Grievances. Manage difficult calls and escalate or triage calls to more experienced staff as necessary.
• Work between multiple systems, utilizing critical thinking and problem-solving skills while successfully keeping the member at the center.
• Identify and keep readily accessible all up-to-date reference documents, policies and procedures needed to be successful.
• People - Attend and contribute to cross-functional member-focused meetings, educate team members on UM functions, and assist members in getting the right care at the right time.
• Utilize knowledge, understanding and critical thinking to research difficult cases related to UM processes and requirements from members, providers, employer groups, agents, member representatives and internal customers.
• Serve as a liaison between members and providers regarding benefit utilization and requirements. Provide education and facilitate the member and provider understanding and experience of utilization processes, including benefit structure, contract parameters, and of the information necessary to effectively complete a prior authorization or inpatient stay.

Supporting Responsibilities:

• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: Minimum of two years of experience in health insurance industry or medical setting required. One year experience working with CPT/HCPCS/ICD coding preferred. Other equivalent professional related experience may be considered.

Education, Certificates, Licenses: High school diploma or equivalent required, associate degree, medical assistant certification, licensed professional nurse or certified professional coding certification preferred.

Knowledge: Demonstrated basic knowledge and understanding of medical terminology, procedures, anatomy, diagnoses, care modalities, treatment plans, and medical coding. Basic understanding of insurance, and standard medical billing practices preferred. Proficient computer, and strong written and verbal communication skills. Strong organizational skills and experience with Microsoft Office programs, medical, and claims management software. The ability to work independently at times with minimal supervision.

Competencies

Building Customer Loyalty

Building Strategic Work Relationships

Contributing to Team Success

Planning and Organizing

Continuous Improvement

Adaptability

Building Trust

Work Standards

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately less than 5% of the time.

Skills:
Accountability, Communication, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

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