UM Coordinator I

PacificSource•Boise, ID

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 multiple sources. It supports compliant utilization management processes, team collaboration, workflow improvement, and strong member and provider relationships. The coordinator creates and documents utilization management cases in electronic records, checks preauthorization requirements and relevant benefit and claims information, and processes inpatient information and events for clinical review. The role collaborates with clinical staff, handles member and provider calls, provides information about utilization processes, and escalates or triages issues as appropriate. It also serves as a liaison between members and providers, helping them understand benefits and the information needed for prior authorizations and inpatient stays. The position requires adherence to departmental performance standards, corporate accuracy and compliance requirements, privacy policies, and HIPAA regulations. It is performed inside 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.
Basic knowledge and understanding 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.
Other equivalent professional related experience may be considered.
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 guidelines to ensure work meets corporate accuracy standards and applicable federal, state, and national accreditation regulations.
Coordinate, create, and document utilization management cases in the electronic record, validating preauthorization requirements and considering 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 CM 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 telephonic 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 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.
Maintain accessible, up-to-date 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.
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.