UM Coordinator I

PacificSource•Bend, OR

5d•Onsite

About The Position

The UM Coordinator I is a member of PacificSource’s utilization management team. The role receives, researches, and coordinates initial and follow-up actions related to clinical documentation and requests from multiple sources. It follows regulatory requirements, supports collaboration and process improvements, and helps strengthen relationships with members and providers. The position coordinates utilization management cases and inpatient information, supports clinical reviews, responds to member and provider inquiries, and helps people understand utilization processes and benefit requirements. Work is performed inside 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.
Proficiency with computers 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 stoop and bend, sit and/or stand for extended periods, perform repetitive typing, sorting, and filing, and lift and carry files and business materials.

Nice To Haves

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

Responsibilities

Meet departmental performance criteria, including timeliness, production, quality, dependability, and member and provider focus.
Follow corporate standards and 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 documenting 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 including diagnosis codes, and triage cases for utilization management 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 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 calls in accordance with HIPAA requirements.
Provide information about prior authorizations, referrals, inpatient admissions and stays, health-related information, determinations, and claims reviews; recognize when to refer members and providers to Appeals and Grievances.
Manage difficult calls and escalate or triage them to more experienced staff when needed.
Use multiple systems, critical thinking, and problem-solving while keeping the member at the center of the work.
Maintain accessible, up-to-date 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 and UM process 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 members and providers about utilization processes, benefit structures, contract parameters, and information needed to complete prior authorizations or inpatient stays.
Meet department and company performance and attendance expectations and comply with PacificSource privacy policies and HIPAA requirements.
Perform other duties as assigned.