Underwriting Clinician Case Manager
PacificSource

Job Info

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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.

Position Overview: Coordinate and respond to all requests for clinical claim (all lines-of-business) reviews across PacificSource Health Plans. Ensure proper utilization of services and resources, medical bill cost assessment, and cost containment. Provide direct assistance to the underwriting and actuarial departments for new and renewing group underwriting requests. Interface with Reinsurance Group of America (RGA). Coordinates with the Health Services staff as needed and indicated for clinical documentation and/or additional information/support. Researches clinical trends and trains PacificSource staff, as necessary.

Essential Responsibilities:

• Identifies high cost utilization and prepares written summary for monthly Large Case Report.
  
• Identifies cases that meet the reinsurance threshold and submits appropriate documentation to the Reinsurer e.g. RGA.
  
• Communicates/meets with RGA representative approximately quarterly to discuss mutually identified topics e.g. ASO groups/deductibles, Large Claim Report questions.
  
• Responds quickly and efficiently to requests for review of future claims costs relative to the clinical presentation of members for new and renewing groups. Demonstrates a knowledge of understanding of how to effectively research and predict future claims costs.
  
• Reviews clinical documentation to ensure appropriate coding and reimbursement for high dollar claims. Demonstrates ability to effectively and efficiently research current usual and customary billing for procedures, diagnostics, inpatient stays, etc.
  
• Coordinate and collaborate with applicable internal and external parties, specific to audit and compliance requirements and reporting.
  
• In coordination with the Claims and other departments, develop and implement a pre and post-payment review system focused on events that generate high dollar claims.
  
• Develop and review Health Services policies, procedures, and desktop references. Standardize workflows across lines-of-business. Collaborate with other departments business as necessary.
  
• Assist with quality of care issues. Identification and appropriate referral to Quality Clinician.
  
• Collaborate with the leadership team, as well as other departments, for Prior Authorization Grid maintenance.
  
• Utilize Lean methodologies for continuous improvement. Utilize visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities.
  
• Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
  
• Identify high-exposure cases, case management or utilization review issues, pertinent inquiries, problems, and decisions that may require review, and inform the Medical Directors. Present and document pertinent information to support recommended action plan. Monitor high-cost cases.
  
• Track and manage provider claims related to caseload. Work with Claims Department to assure timely and accurate adjudication of claims.
  
• Review and audit selected provider claims referred by the Claims Departments. Determine and advise regarding the appropriateness of reimbursement for services, considering diagnosis, elective treatment, regulatory requirements, criteria, and contract provisions.
  
• Represent PacificSource Health Plans with external customers and maintain positive working relationships.
  

Supporting Responsibilities:

• Act as backup for other Health Services Department staff and functions as needed.
  
• Serve on designated committees, teams, and task groups, as directed.
  
• Represent the Heath Services Department, both internally and externally, as requested by the Utilization Management and/or Medical Directors.
  
• 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: Five years of experience with varied medical exposure and experience preferred. Experience in acute care, post-acute care, case management, including cases that require rehabilitation, home health, hospice, and/or behavioral health treatment strongly preferred. Insurance industry experience helpful, but not required. Prior claims review experience and expertise in underwriting preferred. Must have an overall understanding of utilization management and claims costs.

Education, Certificates, Licenses: Registered Nurse or Clinically Licensed Behavioral Health Practitioner with current unrestricted state license. Bachelor's or Master's degree in business, business administration or healthcare administration strongly preferred.

Knowledge: Thorough knowledge and understanding of medical procedures, diagnoses, care modalities, procedures codes including ICD 10 and CPT Codes, health insurance and state-mandated benefits. Expertise in claims review and/or performing underwriting requests. Understanding of contractual benefits and options available outside contractual benefits. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Maintains current clinical knowledge base and certification. Ability to work independently with minimal supervision. Must be able to function as part of a collaborative, cohesive team.

Competencies

• Adaptability
  
• Building Customer Loyalty
  
• Building Strategic Work Relationships
  
• Building Trust
  
• Continuous Improvement
  
• Contributing to Team Success
  
• Planning and Organizing
  
• Work Standards
  

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

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.

This job has expired.