UM Coordinator I

PacificSource•Bend, OR

3d•$35,543 - $56,869

About The Position

The UM Coordinator I supports PacificSource’s utilization management team by receiving, researching, and coordinating initial and follow-up actions related to clinical documentation and requests from multiple sources. The role follows regulatory requirements, contributes to team collaboration and process improvements, and supports positive member and provider relationships. The coordinator creates and documents utilization management cases in electronic records, validates preauthorization requirements, reviews and compiles inpatient information, and coordinates records and case details with clinical staff. The role also provides administrative authorization as directed by UM Leadership, manages incoming calls, explains utilization processes and benefit requirements, and escalates or triages cases and calls when appropriate. This position works inside in a general office setting with ergonomically configured equipment. Travel is required approximately less than 5% of the time.

Requirements

At least two years of experience in the health insurance industry or a medical setting.
High school diploma or equivalent.
Basic knowledge of medical terminology, procedures, anatomy, diagnoses, care modalities, treatment plans, and medical coding.
Proficient computer skills and strong written and verbal communication skills.
Strong organizational skills and experience with Microsoft Office programs, medical software, and claims management software.
Ability to work independently at times with minimal supervision.
Ability to read and comprehend written and spoken English, and communicate clearly and effectively.

Nice To Haves

One year of experience working with CPT, HCPCS, or ICD coding.
Other equivalent professional related experience may be considered.
Associate degree, medical assistant certification, licensed professional nurse credential, or certified professional coding certification.
Basic understanding of insurance and standard medical billing practices.

Responsibilities

Meet department performance criteria for dependability, member and provider focus, timeliness, production, and quality.
Ensure work is accurate and compliant with PacificSource corporate standards and applicable federal, state, and national accreditation regulations.
Coordinate, create, and document utilization management cases in the electronic record, validating preauthorization requirements and recording relevant coding, plan, benefit, eligibility, limitation, exclusion, and claims-history information.
Assess daily inpatient information from external systems and facilities, compile inpatient data, create inpatient events with diagnosis codes, and triage cases for UM and care management clinical staff.
Coordinate information with clinical staff for utilization management, care management, prior authorization, inpatient stays, and retroactive claim reviews.
Integrate medical records as required, document internal or external review status in the medical record, and initiate corrective steps to resolve workflow issues.
Administratively authorize services as directed by UM Leadership.
Manage an active telephonic queue, provide customer service, document HIPAA compliance, respond to inquiries, and forward or escalate calls when necessary.
Work across multiple systems while applying critical thinking and problem-solving skills and keeping the member at the center.
Maintain access to current reference documents, policies, and procedures.
Attend and contribute to cross-functional, member-focused meetings, educate team members about UM functions, and help members obtain appropriate care.
Research difficult UM cases and requirements raised by members, providers, employer groups, agents, member representatives, and internal customers.
Act as a liaison between members and providers regarding benefit utilization and requirements, and explain utilization processes, benefit structures, contract parameters, and information needed for prior authorization or inpatient stays.
Meet department and company performance and attendance expectations.
Follow PacificSource privacy policy and HIPAA requirements for confidentiality and security of protected health information.
Perform other duties as assigned.