UM Coordinator I

PacificSource•Springfield, OR

About The Position

The UM Coordinator I supports the utilization management team by receiving, researching, and coordinating initial and follow-up actions related to clinical documentation and requests from multiple sources. The role follows regulatory requirements, supports 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 ICD, CPT, and HCPCS codes to consider plan types, benefits, eligibility, limitations, exclusions, and claims history. The role also processes inpatient information, creates inpatient events, triages cases for clinical review, coordinates information with clinical teams, integrates medical records, and documents review status. As directed by UM Leadership, the coordinator may administratively authorize services. The position manages an active telephone queue, provides customer service and information about authorizations, referrals, inpatient stays, health-related matters, determinations, and claims review, and refers or escalates issues when appropriate. It works across multiple systems and serves as a liaison between members and providers, helping them understand benefits and utilization processes. The coordinator is expected to meet accuracy, timeliness, quality, attendance, and performance standards and to comply with privacy and HIPAA requirements. The work is performed indoors 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.
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 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.
Other equivalent professional related experience may be considered.

Responsibilities

Meet department performance criteria, including timeliness, production, quality, dependability, and member and provider focus.
Follow corporate standards and applicable federal, state, and national accreditation regulations to ensure accuracy and compliance.
Coordinate, create, and document utilization management cases in the electronic record, validating preauthorization requirements and recording relevant plan, benefit, eligibility, limitation, exclusion, and claims-history information.
Assess daily inpatient information from external systems and facilities, compile inpatient data, create inpatient events with diagnosis codes, and triage cases for review by 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 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 telephone queue, provide customer service, and document HIPAA compliance.
Provide information about prior authorization, referrals, inpatient admissions and stays, health-related information, determinations, and claims review; recognize when to forward members and providers to Appeals and Grievances.
Manage difficult calls and escalate or triage them to more experienced staff as needed.
Use multiple systems, critical thinking, and problem-solving skills while keeping members 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 assist members in accessing 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 structures, 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 laws and regulations concerning confidentiality and security of protected health information.
Perform other duties as assigned.