Special Functions Clinician

1 month ago

Springfield, Illinois, United States PacificSource Full time
Job Title: Special Functions Clinician

Job Summary:

PacificSource is seeking a highly skilled Special Functions Clinician to join our team. As a key member of our Health Services Department, you will play a critical role in ensuring the quality and integrity of our healthcare services.

Key Responsibilities:

  • Coordinate and collaborate with internal and external parties to ensure compliance with audit and reporting requirements.
  • Develop and implement pre and post-payment review systems to identify high-dollar claims.
  • Review and develop Health Services policies, procedures, and desktop references.
  • Collaborate with Medical Directors to develop and review guidelines, policies, and procedures.
  • Assist with quality of care issues, summarize events, and coordinate with the Claims Department to recoup dollars identified with Never Events or Significant Adverse Events.
  • Develop standard workflow processes and utilize Lean methodologies for continuous improvement.
  • Actively participate in strategic and internal committees to disseminate information and represent company philosophy.
  • Identify high-exposure cases, case management, or utilization review issues, and inform the Medical Directors.
  • Present and document pertinent information to support recommended action plans.
  • Monitor high-cost cases, track and manage provider claims, and work with the Claims Department to ensure timely and accurate adjudication.
  • Review and audit selected provider claims referred by the Claims Department.
  • Determine and advise on the appropriateness of reimbursement for services, considering diagnosis, elective treatment, regulatory requirements, criteria, and contract provisions.
  • Represent PacificSource Health Plans with external customers and maintain positive working relationships.
  • Work with Medical Directors to facilitate patient appeals.

Requirements:

  • Five years' experience with varied medical exposure and experience.
  • Experience in acute care, post-acute care, case management, including cases that require rehabilitation, home health, hospice, and/or behavioral health treatment strongly preferred.
  • Insurance industry experience helpful, but not required.
  • Must have an overall understanding of utilization management and claims costs.
  • Project Management experience desirable.

Education, Certificates, Licenses:

  • Registered nurse or Clinically Licensed Behavioral Health Practitioner with current unrestricted state License.
  • Bachelor's or Master's Degree in business, business administration, or healthcare administration strongly preferred.
  • Certified Professional Coding certificate within two years of hire recommended.

Knowledge:

  • Thorough knowledge and understanding of medical procedures, diagnoses, care modalities, procedures codes, including ICD-10, DSM-IV, and CPT Codes, health insurance, and State-mandated benefits.
  • Thorough knowledge of community services, providers, vendors, and facilities available to assist members.
  • Ability to use computerized systems for data recording and retrieval.
  • Assures patient confidentiality, privacy, and health records security.
  • Establishes and maintains relationships with community services and providers.
  • Maintains current clinical knowledge base and certification.
  • Ability to work independently with minimal supervision.

Competencies:

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

Environment:

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

Skills:

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

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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