Utilization Management Specialist (Monday-Friday)

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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.

Essential 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.

Supporting Responsibilities:

• 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.

Work Experience: Three to five years experience in health insurance industry or other medical setting. Thorough knowledge of utilization and case management, including preauthorization required.

Education, Certificates, Licenses: High school degree or equivalent required.

Knowledge: Knowledge of health plan eligibility, benefits and medical interventions/management. Strong knowledge of medical terminology. Experience with medical/dental benefit coordination desired. 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.

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:

$44,982.98 - $71,972.77

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.