PacificSource Health Plans

  • Nurse Team Lead-Commercial Special Functions

    Job Location US-ID-Boise
    Job ID
    Regular Full-Time
    Hiring Pay Range
    71,000 - 85,000
    # of Openings
  • Overview

    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.



    1. Take a leadership role in the development, implementation, and ongoing operation and maintenance of assigned programs, services, or functions.
    2. Improve the performance of the department through effective oversight and coaching of team members, managing team performance and improving processes and outcomes. Monitor daily workflow and caseloads and other work processes of team to assure appropriate distribution and processing of tasks.
    3. Responsible for the orientation and training of new hires.
    4. Provide ongoing supervision, training, evaluation, and leadership to assigned team members. This may include annual reviews, involvement in promotions and/or terminations of employees.
    5. Participate in hiring decisions in concert with Medical Services Director and/or Medical Services Manager and HR.
    6. Monitor and evaluate team assignments relating to volumes, timelines, accuracy, customer service, and other quality and performance measures, and take actions as appropriate.
    7. Assist with process improvement and work with other departments to improve interdepartmental processes. Utilize lean methodologies for continuous improvement.  Utilize visual boards to monitor key performance indicators and identify improvement opportunities.
    8. Serve as liaison with other PacificSource departments or community partners to coordinate optimal provision of service and information. Serve on various internal and external committees as required or designated. Document and report any pertinent communications back to the team or department.
    9. Utilize and promote use of evidence-based medical criteria.
    10. Maintain modified caseload consistent with assigned responsibilities.
    11. Facilitate investigation and resolution of process-related issues as needed. Facilitate conflict resolution, including interfacing with affected departments and individuals, as appropriate.
    12. Oversee and assist in providing exceptional service and information to members, providers, employers, agents, and other external and internal customers.
    13. Provide backup to other departmental teams or management staff, as needed.


    Supporting Responsibilities:

    1. Meet department and company performance and attendance expectations.
    2. Relate new or revised policies, procedures and/or processes to team members to ensure they have the most uptodate and current information.
    3. Facilitate team operations by discussions through the sharing of information and knowledge, identification of teamwork issues, development of problemsolving recommendations, and recommendations of standardizing Health Services operations.
    4. Represent the Heath Services Department, both internally and externally, as requested by Health Services Manager and/or Director.
    5. Perform other duties as assigned


    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.



    Our Values

    •         Building Trust
    •         Building a Successful Team
    •         Aligning Performance for Success
    •         Building Customer Loyalty
    •         Building Strategic Work Relationships
    •         Continuous Improvement
    •         Decision Making
    •         Facilitating Change
    •         Leveraging Diversity
    •         Driving for Results 



    • 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 many 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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