UM Coordinator I

PacificSource•Boise, ID

3d•$35,543 - $56,869

About The Position

The UM Coordinator I is a member of the utilization management team who receives, researches, and coordinates initial and follow-up actions related to clinical documentation and requests from various sources. The role follows regulatory requirements, supports team collaboration and improvement, and helps strengthen member and provider relationships. The coordinator manages utilization management cases and information, supports clinical staff, responds to callers, and helps members and providers understand benefit utilization and authorization processes. The position works in a general office setting with ergonomically configured equipment. Travel is required approximately less than 5% of the time. PacificSource describes itself as an equal opportunity employer and states its commitment to diversity, inclusion, and respect in the workplace.

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 and medical 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 physical requirements of the position, including stooping and bending, extended sitting or standing, repetitive typing, sorting and filing, and light lifting and carrying.

Nice To Haves

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

Responsibilities

Meet departmental performance standards for dependability, member and provider focus, timeliness, production, and quality.
Ensure work meets PacificSource accuracy and compliance standards, including applicable federal, state, and national accreditation requirements.
Coordinate, create, and document utilization management cases in the electronic record; validate preauthorization requirements and account for codes, plan types, benefits, eligibility, limitations, exclusions, and claims history.
Assess daily inpatient information from external systems and facilities, compile inpatient data, create inpatient events with diagnosis codes, and triage cases for UM and CM clinical staff.
Coordinate information with clinical staff for utilization management, care management, prior authorization, inpatient stays, and retroactive claim reviews.
Integrate medical records as needed, document internal and external review status, 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 in accordance with HIPAA requirements, and provide information on authorizations, referrals, inpatient admissions and stays, health-related information, determinations, and claims reviews.
Recognize when to direct members and providers to Appeals and Grievances; manage difficult calls and escalate or triage calls to experienced staff as needed.
Work across multiple systems using critical thinking and problem-solving while keeping members 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.
Liaise between members and providers about benefit utilization and requirements, and educate them about utilization processes, benefit structures, contract parameters, and information needed for prior authorizations or inpatient stays.
Meet department and company performance and attendance expectations.
Follow PacificSource privacy policies and HIPAA laws and regulations concerning the confidentiality and security of protected health information.
Perform other duties as assigned.