UM Coordinator I

PacificSource•Portland, OR

3d•$35,543 - $56,869•Onsite

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 and corporate standards, contributes to team improvements and collaboration, and supports positive relationships with members and provider partners. The coordinator creates and documents utilization management cases in electronic records, validates preauthorization requirements, reviews member benefits and related information, compiles inpatient data, and routes cases for clinical review. The role works with clinical staff on utilization management, care management, prior authorization, inpatient stays, and retroactive claim reviews; integrates medical records when needed; and documents review status. It also handles administrative authorizations as directed by UM leadership and manages a telephonic queue, providing information and escalating or triaging calls as appropriate. The position serves as a liaison between members and providers, helping explain benefit utilization, requirements, and utilization processes. It requires attention to accuracy, compliance, confidentiality, customer service, and performance expectations. The work is performed inside a general office setting with ergonomically configured equipment, and travel is required approximately less than 5% of the time.

Requirements

Minimum of two years of experience in the health insurance industry or a medical setting.
High school diploma or equivalent.
Demonstrated 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.
Ability to meet the position’s physical requirements, including stooping and bending; sitting and/or standing for extended periods; repetitive typing, sorting, and filing; and light lifting and carrying of files and business materials.

Nice To Haves

One year of experience working with CPT/HCPCS/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.
Follow corporate standards and applicable federal, state, and national accreditation requirements to ensure accuracy and compliance.
Coordinate, create, and document utilization management cases in the electronic record, validating preauthorization requirements and recording relevant plan, member, benefit, eligibility, limitation, exclusion, and claims-history information.
Assess daily inpatient information from external systems and facilities, compile inpatient data, create inpatient events including diagnosis codes, and triage cases for UM and care management clinical staff.
Collaborate with clinical staff on utilization management, care management, prior authorization, inpatient stays, and retroactive claim reviews.
Integrate medical records as required and document the status of internal or external reviews in the medical record.
Identify workflow issues and promptly initiate corrective steps.
Administratively authorize services as directed by UM leadership.
Manage an active telephonic queue, provide customer service, and document HIPAA compliance.
Provide information about prior authorization, referrals, inpatient admissions and stays, health-related information, determinations, and claims review; identify when to forward members and providers to Appeals and Grievances.
Manage difficult calls and escalate or triage calls to more experienced staff when appropriate.
Use multiple systems and critical-thinking and problem-solving skills while keeping the member at the center of the work.
Maintain ready access to current reference documents, policies, and procedures.
Attend and contribute to cross-functional, member-focused meetings; educate team members on UM functions; and assist members in accessing appropriate care.
Research difficult cases involving UM processes and requirements for members, providers, employer groups, agents, member representatives, and internal customers.
Serve as a liaison between members and providers regarding benefit utilization and requirements; educate them about utilization processes, benefit structure, contract parameters, and information needed to complete prior authorizations 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.