UM Coordinator I

PacificSource•WFH: NC, NC

3d•$35,543 - $56,869

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 various sources. It supports compliance with regulatory requirements, team collaboration and improvement, and positive member and provider relationships. The coordinator creates and documents utilization management cases in electronic records, validates preauthorization requirements, reviews inpatient information, and coordinates information with clinical staff. The role also manages a telephonic queue, responds to questions about utilization management processes, and helps members and providers understand benefits and authorization requirements. Work requires accuracy, confidentiality, sound judgment, and effective use of multiple systems. The position works inside in a general office setting with ergonomically configured equipment. Travel is required approximately less than 5% of the time. Physical requirements include 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.

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.
Skills in accountability, collaboration, written and verbal communication, flexibility, active listening, organization and planning, problem solving, and teamwork.

Nice To Haves

One year of experience working with CPT, HCPCS, or ICD coding.
Equivalent professional related experience may be considered in place of the stated work experience.
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 standards for dependability, member and provider focus, timeliness, production, and quality.
Follow PacificSource corporate standards and applicable federal, state, and national accreditation requirements for accuracy and compliance.
Coordinate, create, and document UM cases in the electronic record; validate preauthorization requirements and consider 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 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 needed 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 authorizations, referrals, inpatient admissions and stays, health-related information, determinations, and claims review; recognize when to direct members and providers to Appeals and Grievances.
Manage difficult calls and escalate or triage calls to more experienced staff when necessary.
Use multiple systems and critical-thinking and problem-solving skills while keeping the member at the center of the work.
Keep current reference documents, policies, and procedures readily accessible.
Attend and contribute to cross-functional, member-focused meetings; educate team members on UM functions; and help members get appropriate care at the right time.
Research difficult cases and UM process requirements raised by members, providers, employer groups, agents, member representatives, and internal customers.
Serve as a liaison between members and providers regarding benefit utilization and requirements; provide education 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 requirements for confidentiality and security of protected health information.
Perform other duties as assigned.