Accountable for the effective management of the staff working in Special Functions (medical claim review, Health Services related appeals, policies and procedures, new technologies and support for Dynamo and it’s interfaces to Facets). Responsible for hiring, training, coaching, counseling, and evaluating team member performance. May be called upon to perform routine day-to-day program functions. Actively participate in program development and implementation. Supervise and provide guidance to direct reports and other department staff regarding company policies, procedures, and operations. Manage the quality and productivity of team tasks and workflow as they relate to both assigned functions and the overall effectiveness of the Health Services team. Work to resolve issues and improve processes and outcomes.
Work Experience: A minimum of five years clinical experience required. Minimum of three years direct health plan experience in the following areas: utilization management, grievance and appeal, and claims review strongly preferred. Prior supervisory experience preferred.
Education, Certificates, Licenses: Registered Nurse with current appropriate unrestricted state license. Certified Professional Coding certificate strongly desired or willingness to obtain certification with two years of hire.
Knowledge: Knowledge of health insurance and state mandated benefits. Thorough knowledge and understanding of medical procedures, diagnoses, care modalities, procedure codes, including current versions of ICD, DSM, and CPT Codes. Thorough knowledge and understanding of contractual benefits and options available outside contractual benefits. Effective adult education/teaching and/or group leadership skills. Strong analytical and organizational skills with experience in using information systems and computer applications. Is flexible. Ability to develop, review, and evaluate utilization management reports. Strong computer skills including experience with Word, Excel, and PowerPoint. Ability to use audio-visual equipment. Ability to work independently with minimal supervision.
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.