UM Coordinator I

PacificSource Health Plans; United States; Remote; USD 36,000 - 57,000; Full time

Job summary

PacificSource Health Plans is seeking a Utilization Management Coordinator I to support clinical documentation and preauthorization workflows. You will coordinate UM cases, validate CPT/HCPCS/ICD requirements, and document actions in the electronic record with accuracy.

You will collaborate with UM, care management, and provider teams to ensure timely, compliant determinations, while maintaining HIPAA privacy and delivering high-quality member service.

Qualifications

• Knowledge of CPT/HCPCS/ICD terminology and medical coding basics.
• Experience with health insurance or medical settings preferred.
• Strong written and verbal communication in a healthcare context.
• Ability to work independently with minimal supervision.

Responsibilities

• Coordinate, create, and document UM cases in electronic records.
• Validate preauthorization requirements and reference codes.
• Maintain HIPAA compliance and protect member information.
• Manage telephonic queue and provide member/provider education.
• Collaborate with clinical staff to align UM, care management, and prior authorizations.

Skills

Communication

Teamwork

Accountability

Collaboration

Organizational skills

Problem solving

Listening

Education

High school diploma or equivalent

Associate degree

Medical assistant certification

Licensed professional nurse

Certified professional coder cert

Tools

Microsoft Office

Medical/claims management software

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 insurance, and standard medical billing practices preferred. Proficient computer, and strong written and verbal communication skills. Strong organizational skills and experience with Microsoft Office programs, medical, and claims management software. The ability to work independently at times with minimal supervision.

Competencies

Building Customer Loyalty

Building Strategic Work Relationships

Contributing to Team Success

Planning and Organizing

Continuous Improvement

Adaptability

Building Trust

Work Standards

Environment:

Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately less than 5% of the time.

Skills:

Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork

Compensation Disclaimer

The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.

Base Range:

$35,542.81 - $56,868.50

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.

• We are one team working toward a common goal.

• We are each responsible for customer service.

• We practice open communication at all levels of the company to foster individual, team and company growth.

• We actively participate in efforts to improve our many communities-internally and externally.

• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.

• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements:

Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer:

This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.