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, national origin, sex, sexual orientation, gender identity or age.
Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.
Nature and Scope:
Provide administrative and analytic support for the Health Services Department. Handle initial steps of preauthorizations, referrals, case management, and/or claims reviews. Gather data from hospitals, providers, and members. Research eligibility, benefits, and planned medical interventions. Obtain clinical information and other data needed to make determinations. Enter appropriate information into system. Assist professional staff with medical management processes.
Receive and analyze incoming department telephone calls, including preauthorization requests, referrals, hospital admissions, and other medical management related calls. Initiate preauthorization process.
Verify information and work with professional staff to prepare preauthorization notices.
Enter information into computer system and generates preauthorization notices or letters.
Send notices to providers, facilities, and members, and complete departmental documentation. Initiate referral process for members with PacificSource as the authorizing entity, and enter information into the computer system.
Receive referral authorization information from other authorizing entities, verify documentation, and enter information into the computer system.
Receive daily admitting information from hospitals and compile hospital census data, including ICD-9 diagnosis codes.
Work with Nurse Case Managers to generate daily hospital census reports and notify hospitals of initial utilization review determinations as directed. Handle customer service calls related to medical information or determinations.
Assist professional staff with obtaining information for case management, precertification, and retroactive claims reviews.
Request medical records as required and document status of review in the computer system.
Make guideline-directed determinations under the authority and direction of the professional staff.
Research and document information needed by department, company, and professional staff in making medical determinations related to precertification, case management, claims review, appeals, or other medical management functions.
File, send out notices, and perform miscellaneous clerical tasks and special projects for the department, as needed.
Provide word processing back-up for Health Services Department, or as directed by the manager. P
rovide telephone answering and customer service call back-up for all department personnel.
Represent department, both internally and externally, as required.
Perform other duties as required.
Relationships: Function as a participating member of the team. Interact on a professional level with members, medical professionals, PacificSource employees, and others conducting business with PacificSource.
Work Experience: 1+ year of experience in the health insurance industry or a medical background highly desirable.
Language skills: Excellent written and oral communication skills needed in order to communicate effectively with medical and legal professionals.
Mathematical Skills: Basic math skills required, including percentages, ratios, graphing and spreadsheet skills.
Reasoning Ability: Ability to prioritize responsibilities and to diplomatically handle difficult situations.
Education, Certificates, Licenses, Registration: High school diploma or equivalent required.
Other Skills and Abilities:
Accountable for the accurate and efficient completion of all duties.
Charged with being consistently helpful, confident, professional, and pleasant when working with a wide variety of personalities while supporting PacificSource's decisions.
Responsible for documentation of information given and received. Supports the PacificSource mission and expectations for service, accuracy and efficiency. Conforms to departmental standards and supports the mission of the department.
This position is accountable for processing, and/or acting upon information which is confidential in nature and maintaining the security of such information.
Accountable for understanding the concept of internal and external customers and the importance of courtesy to all. Knowledge of and skill in the use of personal computers and MSWord required.
General clerical, written and oral communications skills, medical terminology required.
Ability to analyze and provide timely and accurate responses.
Work inside in a general office setting with ergonomically configured equipment.
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 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.