UM Coordinator I (Tuesday-Saturday)

PacificSource Health Plans•WFH: MO, MO

2d•$35,543 - $56,869•Onsite

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 varied sources. The role 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, reviews inpatient information, and coordinates information with clinical staff. The position also manages incoming calls, provides information about utilization processes and benefits, documents in accordance with HIPAA requirements, and escalates or triages inquiries as needed. It works across multiple systems and serves as a liaison between members and providers to explain benefit utilization and requirements. The position is based inside a general office setting with ergonomically configured equipment. Travel is required less than 5% of the time. The schedule is Tuesday through Saturday.

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.
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.
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 in place of the stated work experience.

Responsibilities

Meet department performance standards for dependability, member and provider focus, timeliness, production, and quality.
Follow corporate standards and federal, state, and national accreditation requirements to ensure accuracy and compliance.
Coordinate, create, and document UM cases in electronic records; 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 required, document the status of internal or external reviews, and promptly initiate corrective steps to resolve workflow issues.
Administratively authorize services as directed by UM Leadership.
Manage an active telephone queue, provide customer service, document HIPAA compliance, answer questions about authorizations, referrals, admissions, stays, health-related information, determinations, and claims review, and refer callers to Appeals and Grievances when appropriate.
Manage difficult calls and escalate or triage them to more experienced staff as needed.
Work across multiple systems using critical thinking and problem-solving skills while keeping the member at the center.
Maintain ready access to current reference documents, policies, and procedures.
Attend and contribute to cross-functional, member-focused meetings; educate team members on UM functions; and help members get 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; explain utilization processes, benefit structure, contract parameters, and information needed for prior authorization 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.