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Healthcare Utilization Analyst I

2 months ago

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

Join PacificSource and play a vital role in helping our members gain access to quality and affordable healthcare services.

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

Diversity and Inclusion: At PacificSource, we value the diversity of our workforce and the communities we serve. We are dedicated to fostering an inclusive environment where individual differences are recognized, respected, and utilized to enhance the talents and strengths of each team member.

The Utilization Management (UM) Coordinator I is a key member of the utilization management team, responsible for receiving, researching, and coordinating initial and follow-up actions related to clinical documentation and requests from various sources. This role adheres to strict regulatory standards, promotes team collaboration, contributes to process improvements, and strengthens relationships with both members and provider partners.

Key Responsibilities:
  • Dependability: Maintain high standards of reliability, member and provider focus, and meet all performance metrics established by the department, including timeliness, production, and quality benchmarks.
  • 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 system by validating preauthorization requirements, utilizing a foundational understanding of ICD, CPT, and HCPCS codes, and including details on 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 teams to synchronize information for utilization management, care management, prior authorizations, 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 initiate corrective actions to resolve workflow challenges promptly.
  • Administer authorization of services as directed by UM Leadership.
  • Effectively manage an active telephonic queue, providing excellent customer service to incoming callers while ensuring HIPAA compliance. Offer information on prior authorizations, referrals, inpatient admissions, health-related inquiries, determinations, claims reviews, and recognize when to escalate issues to Appeals and Grievances.
  • Navigate multiple systems, employing critical thinking and problem-solving skills while keeping the member's needs at the forefront.
  • Maintain an organized collection of up-to-date reference documents, policies, and procedures essential for success.
  • Team Collaboration: Participate in cross-functional meetings focused on member needs, educate team members on UM functions, and assist members in accessing the right care at the right time.
  • Utilize knowledge and critical thinking to investigate complex cases related to UM processes and requirements from members, providers, employer groups, agents, and internal stakeholders.
  • Act as a liaison between members and providers regarding benefit utilization and requirements, providing education and facilitating understanding of utilization processes, including benefit structures and necessary information for prior authorizations 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 assigned duties as needed.
Success Profile:

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

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

Competencies:

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

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

Skills:
Accountability, Communication (written and verbal), Flexibility, Active Listening, Organizational Skills, Problem Solving, Teamwork

Our Values:

We embody our values, which guide our business practices:
  • Commitment to doing the right thing.
  • Collaboration as one team toward a common goal.
  • Responsibility for customer service at all levels.
  • Open communication to foster growth.
  • Active participation in community improvement efforts.
  • Advancement of social justice, equity, diversity, and inclusion.
  • Encouragement of 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. Proficiency in reading and comprehending both written and spoken English, along with clear and effective communication.

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 for this role. Employment remains at-will at all times.