PacificSource Health Plans

Health Services Representative II

US-OR-Bend
Job ID
2017-427
Type
Regular Full-Time
Hiring Pay Range
$16.00- $17.50 per hour
# of Openings
1
Status
Non-Exempt

Overview

Position Overview: Provide administrative and analytic support for the Health Services Department. Handle initial steps of preauthorization’s, 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.

Responsibilities

Essential Responsibilities:

  1. Effectively handle incoming department telephone calls, including those related to preauthorization requests, referrals, hospital      admissions, medical information, determinations, or claims review. 
  2. 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. 
  3. 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.
  4. Receive daily admitting information from hospitals and compile hospital census data, including ICD diagnosis codes. Work with Case Managers to generate daily hospital census reports and notify hospitals of initial utilization review determinations as directed.
  5. 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. 
  6. Make guideline-directed determinations under the authority and direction of the professional staff.
  7. 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. 
  8. Scan, copy, send out notices, and perform a variety of clerical tasks and special projects for the department, as needed.
  9. Provide word processing back-up for Health Services Department, or as directed by the manager. 

        

Supporting Responsibilities:

  1. Represent department, both internally and externally, as required.
  2. Meet department and company performance and attendance expectations.
  3. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
  4. Perform other duties as assigned.

Qualifications

Work Experience: 1+ year of experience in the health insurance industry or a medical background required.

 

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

 

Knowledge: 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. 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.

 

Competencies

Our Values

  • Adaptability
  • Building Customer Loyalty
  • Building Strategic Work Relationships
  • Building Trust
  • Continuous Improvement
  • Contributing to Team Success
  • Planning and Organizing
  • Work Standards
  • We are committed to doing the right thing.
  • We are one team working toward a common goal.
  • We are each responsible for our customers’ experience.
  • 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 communities-internal and external.
  • We encourage creativity, innovation, continuous improvement, and the pursuit of excellence.

 

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

 

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.

 

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.

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