Utilization Management Specialist (Monday-Friday)

PacificSource Health Plans•Salem, OR

About The Position

Looking for a way to make an impact and help people? Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths. Facilitate workflow for specific utilization management activities. Serve as a member on the Utilization Management Team. Provide and coordinate dental/medical authorization processes in collaboration with the consulting dentist. Ensure member satisfaction and help to establish service-related best practice standards. Support department goals.

Requirements

Three to five years experience in health insurance industry or other medical setting.
Thorough knowledge of utilization and case management, including preauthorization required.
High school degree or equivalent required.
Knowledge of health plan eligibility, benefits and medical interventions/management.
Strong knowledge of medical terminology.
Ability to work under time constraints.
Proficient in Microsoft Office including Word and Excel, medical and dental terminology, CPT/ICD-9 coding, claims payment systems (e.g. Facets), and Medical management software (e.g. Dynamo).
Ability to prioritize responsibilities and to diplomatically handle demanding situations.
Ability to work independently as well as be able to work effectively on a team.
Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork

Nice To Haves

Experience with medical/dental benefit coordination desired.

Responsibilities

Review advanced level PA’s such as, but not limited to those pertaining to dental/medical, hysteroscopies, initial varicose vein treatments, laproscopies.
Document pertinent information which supports recommended action plan.
Make determinations based on approved criteria.
Act as primary contact and coordinator of issues related to the dental/medical authorization process including member and provider communications.
Provide telephone answering and customer service for the Health Services Department.
Assist employers and agents with questions regarding healthcare resources and procedures for their employees and clients.
Serve as a liaison to PacificSource departments to facilitate provision of services and information.
Enter and collate data; prepare reports as assigned.
Participate in new staff orientation.
Contribute to a positive work environment.
Actively engage with identifying, developing, and executing department goals.
Participate in team, department, company, and committee-related meetings as requested.
Actively participate in quality improvement initiatives.
Meet department and company performance and attendance expectations.
Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
Perform other duties as assigned.

Benefits

Flexible telecommute policy, medical, vision, and dental insurance, incentive program, paid time off and holidays, 401(k) plan, volunteer opportunities, tuition reimbursement and training, life insurance, and options such as a flexible spending account.

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