Special Functions Clinician

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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, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

The Special Functions role is a compilation of various tasks and duties to include/but not limited to: pre, post, and focused audits, clinical component of appeals, policy preparation and review, creation of Desk Top References, compliance auditing, education, and quality event review. To accomplish these deliverables, the Special Functions Clinician will collaborate with internal partners/departments to ensure practices align with all line of business (LOB), meet the needs of our members, and adhere to regulatory requirements.

Essential Responsibilities:

• In coordination with the Claims Department and other departments, as applicable, develop and implement a pre and post-payment review system focused on events that generate high dollar claims.
• Identify and escalate discrepancies in payment rates, coding accuracy, and authorization processes.
• Maintain comprehensive records of transactions, audit findings, and corrective actions.
• Develop and maintain dashboards and reports to track audit outcomes, refund activity, and payer performance, ensuring data-driven transparency and accuracy of cost savings activities
• Leverage claims management systems and data analytics tools to enhance audit accuracy and efficiency, while collaborating with IT and system administrators to optimize payer configuration and system integrity.
• Develop and review Health Services policies, procedures, and desktop references. Collaborate with other departments and/or lines of business as necessary.
• Assist Medical Directors in developing and reviewing guidelines, policies and procedures for the Health Services Department.
• Assist with quality-of-care issues. Summarize the event and collaborate with the LOB Medical Directors for outcome. Coordinate with Claims Department to recoup dollars identified with Never Events or Significant Adverse Events.
• Collaborate with the leadership team, as well as other departments for Prior Authorization Grid maintenance.
• Develop standard workflow processes.
• 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 advice 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.
• Work with Medical Directors to facilitate patient appeals. Prepare case presentations, as directed, for Medical Grievance Review Claims and Utilization Review Committee, Policy and Procedure Review Committee (PPRC), and/or the Membership Rights Panel (MRP).

Supporting Responsibilities:

• Serve on designated committees, teams, and task groups, as directed.
• Represent the Heath Services Department, both internally and externally, as requested by Medical Director, Utilization Management Director, and Health Services Managers
• 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.
• Meet department and company performance and attendance expectations.
• Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: Minimum of 3 years of experience with varied medical exposure and experience. 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. Must have an overall understanding of utilization management and claims costs. Project Management experience desirable.

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. Certified Professional Coding certificate within two years of hire recommended.

Knowledge: Thorough knowledge and understanding of medical procedures, diagnoses, care modalities, procedures codes including ICD-10, DSM-IV, and CPT Codes, health insurance, and State-mandated benefits. Thorough knowledge of community services, providers, vendors, and facilities available to assist members. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. Ability to work independently with minimal supervision.

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.

Skills:

Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork

Compensation Disclaimer

The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range.

Base Range:

$70,950.00 - $106,424.99Our 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.