UM Coordinator I

PacificSource Health Plans•Springfield, OR

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 a variety of sources. It follows regulatory requirements, supports team collaboration and process improvements, and helps strengthen relationships with members and provider partners. The coordinator creates and documents utilization management cases in electronic records; validates preauthorization requirements; and uses a basic understanding of medical coding, plan types, member benefits, eligibility, limitations, exclusions, and claims history. The position also compiles and validates inpatient information, creates inpatient events, and routes cases to clinical staff for review. It coordinates information across utilization management, care management, prior authorization, inpatient stays, and retroactive claim reviews, and administratively authorizes services as directed by UM Leadership. The role manages an active telephone queue, provides customer service and information about utilization processes, documents calls in accordance with HIPAA requirements, and escalates or triages calls as appropriate. It researches complex questions, serves as a liaison between members and providers, and educates them about benefits, requirements, and information needed for prior authorizations or inpatient stays. The position works in an indoor general office setting with ergonomically configured equipment and requires travel 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.
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.

Nice To Haves

One year of experience working with CPT, HCPCS, or 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.
Equivalent professional related experience may be considered in place of the stated work experience.

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 the electronic record, validating preauthorization requirements and relevant plan, benefit, eligibility, claims, and coding information.
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 review.
Coordinate information with clinical staff across 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, document in accordance with HIPAA requirements, answer questions about authorization, referrals, admissions, stays, health-related information, determinations, and claims review, and route callers to Appeals and Grievances when appropriate.
Escalate or triage difficult calls to more experienced staff when necessary.
Work across multiple systems using critical thinking and problem-solving skills while keeping the member at the center.
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 access appropriate care.
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, 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.