UM Coordinator I

PacificSource•Portland, OR

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 a variety of sources. The role follows regulatory requirements, supports collaboration and team improvements, and helps strengthen member and provider relationships. The coordinator creates and documents utilization management cases in electronic records, validates preauthorization requirements, and uses a basic understanding of ICD, CPT, and HCPCS codes to consider plan types, benefits, eligibility, limitations, exclusions, and claims history. The role also processes inpatient information and events, coordinates documentation and reviews with clinical staff, administratively authorizes services as directed by UM leadership, and manages calls from members and providers. The position requires a minimum of two years of experience in the health insurance industry or a medical setting. A high school diploma or equivalent is required. Work is performed 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; other equivalent professional related experience may be considered.
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.

Nice To Haves

One year of experience working with CPT/HCPCS/ICD coding.
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 accuracy and compliance standards, including applicable federal, state, and national accreditation regulations.
Coordinate, create, and document UM cases in electronic records; validate preauthorization requirements and account for applicable 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 including diagnosis codes, and triage cases for UM and CM clinical staff review.
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 and promptly initiate corrective steps to resolve workflow issues.
Administratively authorize services as directed by UM leadership.
Manage an active telephonic queue, provide customer service, and document HIPAA compliance.
Provide information on 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.
Work across multiple systems and use critical thinking and problem-solving skills while keeping the member at the center.
Keep up-to-date reference documents, policies, and procedures readily accessible.
Attend and contribute to cross-functional member-focused meetings, educate team members on UM functions, and assist members in getting appropriate care.
Research difficult UM cases and 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.
Educate members and providers 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 concerning confidentiality and security of protected health information.
Perform other duties as assigned.