Utilization Management Specialist I

PacificSource; Idaho; On-site; USD 36,000 - 57,000; Full time

Benefits offered by this job

Flexible telecommute

Medical insurance

Vision insurance

Dental insurance

Incentive program

Paid time off

401(k) plan

Tuition reimbursement

Life insurance

Flexible spending account

Job summary

PacificSource is seeking a dedicated UM/Utilization Management professional to coordinate and document cases, validate preauthorization needs, and collaborate with clinical staff. You will handle inpatient data, eligibility, and claims history, ensuring compliance with HIPAA and accreditation standards.

The role emphasizes accuracy, problem solving, and strong communication with members and providers, including guidance on prior authorization processes.

Qualifications

• Knowledge of CPT/HCPCS/ICD coding and related terminology.
• Experience in health insurance or medical setting preferred.
• Understanding of HIPAA and confidentiality requirements.

Responsibilities

• Coordinate, create, and document utilization management (UM) cases, including preauthorization.
• Assess inpatient information, compile data, and triage for review by clinical staff.
• Educate and assist members and providers on benefit requirements and prior authorizations.

Skills

CPT Coding

HCPCS Coding

ICD Coding

Communication

Teamwork

Education

High school diploma or equivalent

Associate degree

Medical assistant certification

Licensed professional nurse

Certified professional coding certification

Job description

PacificSource is seeking a dedicated UM/Utilization Management professional to coordinate and document cases, validate preauthorization needs, and collaborate with clinical staff. You will handle inpatient data, eligibility, and claims history, ensuring compliance with HIPAA and accreditation standards.

The role emphasizes accuracy, problem solving, and strong communication with members and providers, including guidance on prior authorization processes.