Utilization Management Coordinator I

2 weeks ago

Springfield, United States PacificSource Full time
Are you passionate about making a difference in healthcare?

Join PacificSource and support our members in accessing high-quality, affordable healthcare services.

PacificSource is committed to equal opportunity employment. All qualified candidates will be considered for employment without regard to veteran status, disability, or other protected statuses, including race, religion, color, national origin, sex, sexual orientation, gender identity, or age.

Diversity and Inclusion: At PacificSource, we value the diverse backgrounds of our employees and the communities we serve. We strive to create an inclusive environment that respects and appreciates individual differences, enabling everyone to reach their full potential.

The Utilization Management (UM) Coordinator I plays a crucial role within the utilization management team, responsible for receiving, investigating, and coordinating initial and follow-up actions related to clinical documentation and requests from various sources. This position adheres to strict regulatory standards, fosters team collaboration, contributes to team enhancements, and strengthens relationships with both members and provider partners.

Key Responsibilities:
  • Dependability: Maintain high standards of reliability, member and provider focus, and performance metrics as defined by the department, including timeliness, production, and quality benchmarks for all tasks.
  • Ensure compliance with PacificSource corporate standards for accuracy and adherence to federal, state, and national accreditation regulations.
  • UM Process: Manage, create, and document UM cases in the electronic record by verifying preauthorization requirements, applying a foundational understanding of ICD, CPT, and HCPCS codes, and including plan types, member benefits, eligibility, limitations, exclusions, and claims history.
  • Evaluate the accuracy of daily inpatient data from external systems and facilities, compile inpatient information, create inpatient events with diagnosis codes, and triage for review by UM and CM clinical staff.
  • Collaborate with clinical personnel to synchronize information for utilization management, care management, prior authorization, inpatient stays, and retroactive claim reviews. Integrate medical records as necessary and document the status of internal or external reviews in the medical record. Identify and promptly initiate corrective actions to resolve workflow challenges.
  • Administratively authorize services as directed by UM Leadership.
  • Effectively manage an active telephonic queue, providing excellent customer service to incoming callers and ensuring HIPAA compliance. Offer information on prior authorizations, referrals, inpatient admissions, health-related inquiries, determinations, claims reviews, and know when to direct members and providers to Appeals and Grievances. Handle challenging calls and escalate or triage as needed.
  • Navigate multiple systems while utilizing critical thinking and problem-solving skills, always keeping the member's needs at the forefront.
  • Maintain an accessible collection of up-to-date reference documents, policies, and procedures essential for success.
  • Team Collaboration: Participate in cross-functional member-focused meetings, educate team members on UM functions, and assist members in receiving appropriate care in a timely manner.
  • Employ knowledge and critical thinking to investigate complex cases related to UM processes and requirements from members, providers, employer groups, agents, member representatives, and internal customers.
  • Act as a liaison between members and providers regarding benefit utilization and requirements. Provide education and facilitate understanding of utilization processes, including benefit structures, contract parameters, and necessary information for effective prior authorization or inpatient stays.
Additional Responsibilities:
  • Meet departmental and organizational performance and attendance expectations.
  • Adhere to PacificSource privacy policies and HIPAA regulations concerning the confidentiality and security of protected health information.
  • Perform other duties as assigned.
Success Profile:

Work Experience: A minimum of two years in the health insurance sector or medical environment is required. One year of experience with CPT/HCPCS/ICD coding is preferred. Equivalent professional experience may be considered.

Education, Certificates, Licenses: A high school diploma or equivalent is required; an associate degree, medical assistant certification, licensed professional nurse, or certified professional coding certification is preferred.

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

Competencies:

Building Customer Loyalty
Building Strategic Work Relationships
Contributing to Team Success
Planning and Organizing
Continuous Improvement
Adaptability
Building Trust
Work Standards

Work Environment: This position is primarily office-based with ergonomically configured equipment. Travel is required approximately less than 5% of the time.

Skills:
Accountability, Communication, Flexibility, Active Listening, Organizational Skills, Problem Solving, Teamwork

Our Values:
We are guided by our core values that shape our business practices:
  • Commitment to doing the right thing.
  • Working as one team towards a common goal.
  • Responsibility for customer service.
  • Open communication at all levels to foster growth.
  • Active participation in community improvement efforts.
  • Advancing social justice, equity, diversity, and inclusion.
  • Encouraging creativity, innovation, and excellence.
Physical Requirements: Ability to stoop, bend, sit, and/or stand for extended periods while performing core job functions. Repetitive motions including typing, sorting, and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Clear and effective communication is essential.

Disclaimer: This job description outlines the general nature and level of work performed by employees in this position and is subject to change. It is not intended to be a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this role. Employment remains at-will at all times.

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