UM Coordinator I

PacificSource; Boise (ID); On-site; USD 42,000 - 62,000; Full time

Job summary

PacificSource is seeking an Utilization Management Coordinator I to join our team. You will research and coordinate initial and follow-up clinical documentation, ensure regulatory compliance, and support UM processes with accuracy in the electronic record.

You will collaborate with clinical staff, assist in prior authorizations, and help maintain a high standard of member and provider relations, all while protecting HIPAA privacy and delivering quality service.

Qualifications

• Minimum of two years of experience in health insurance or medical setting.
• Basic understanding of CPT/HCPCS/ICD coding.
• Knowledge of medical terminology, procedures, anatomy, and care modalities.

Responsibilities

• Research and coordinate initial and follow-up clinical documentation for UM requests.
• Adhere to regulatory requirements and maintain HIPAA compliance in all handling of records.
• Coordinate UM cases, validate preauthorization requirements, and document in the electronic record.
• Collaborate with clinical staff to synchronize information for UM and care management.
• Administer services as directed by UM leadership and manage calls with sensitivity and professionalism.

Skills

Customer service

HIPAA compliance

Medical terminology

Problem solving

Communication

Education

High school diploma

Associate degree preferred

Medical assistant certification preferred

Licensed practical nurse / registered nurse preferred

Certified professional coder preferred

Job description

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.

The Utilization Management (UM) Coordinator I is fundamental to the utilization management team and receives, researches, and coordinates initial and follow-up action related to clinical documentation and requests from a variety of sources. Adheres to rigorous regulatory requirements, builds team collaboration, contributes to team improvements, and creates enhanced member and provider partner relationships.

Essential Responsibilities

• High level - Adhere to dependability, member and provider focus, and all performance criteria as established by the department including: timeliness, production, and quality standards for all functions.
• Follow stringent guidelines to ensure all work meets PacificSource corporate standards for accuracy and compliance with federal, state, and national accreditation regulations.
• UM Process - Coordinate, create, and document UM cases in the electronic record by validating preauthorization requirements, utilizing a basic understanding of ICD, CPT and HCPCS codes, and including plan types, member benefits, eligibility, limitations, exclusions, and claims history.
• Assess accuracy of daily inpatient information from external systems and inpatient facilities, compile inpatient data, create inpatient events including diagnosis codes, and triage for review by UM and CM clinical staff.
• Collaborate with clinical staff by synchronizing information for utilization management, care management, prior authorization, inpatient stay, and retroactive claim reviews. Integrate medical records as required and document 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.
• Effectively manage an active telephonic queue by delivering excellent customer service to incoming caller and documenting HIPAA compliance. Provide information on prior authorization, referrals, inpatient admissions and stays, health-related information, determinations, claims review, and possess an understanding of when to forward members and providers to Appeals and Grievances. Manage difficult calls and elevate or triage calls to more experienced staff as necessary.
• Work between multiple systems, utilizing critical thinking and problem-solving skills while successfully keeping the member at the center.
• Identify and keep readily accessible all up-to-date reference documents, policies and procedures needed to be successful.
• People - Attend and contribute to cross-functional member-focused meetings, educate team members on UM functions, and assist members in getting the right care at the right time.
• Utilize knowledge, understanding and critical thinking to research difficult cases related to UM processes and requirements from members, providers, employer groups, agents, member representatives and internal customers.
• Serve as a liaison between members and providers regarding benefit utilization and requirements. Provide education and facilitate the member and provider understanding and experience of utilization processes, including benefit structure, contract parameters, and of the information necessary to effectively complete a prior authorization or inpatient stay.

Supporting Responsibilities

• 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.

SUCCESS PROFILE

• Work Experience: Minimum of two years of experience in health insurance industry or medical setting required. One year experience working with CPT/HCPCS/ICD coding preferred. Other equivalent professional related experience may be considered.
• Education, Certificates, Licenses: High school diploma or equivalent required, associate degree, medical assistant certification, licensed professional nurse or certified professional coding certification preferred.
• Knowledge: Demonstrated basic knowledge and understanding of medical terminology, procedures, anatomy, diagnoses, care modalities, treatment plans, and medical coding. Basic understanding of insuran