Utilization Management Team Leader
PacificSource

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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, 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.

Manage the services, functions and personnel, including accountability for operational aspects and delegation of duties to the Health Service Representatives (HSRs). Responsible for hiring, training, coaching, counseling, and evaluating team members' performance. Coordinate application of services and benefits. Handle Medical Services-related inquiries and communicate benefit determinations. Act as a liaison and information resource to internal and external customers.

Essential Responsibilities:

• Compile and manage Health Services (HS) statistics related to PRISM, regulatory requirements and other monthly reports. Analyze medical services utilization data to formulate recommendations for maintaining and improving the delivery of services to our members and providers.
• Assist with hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback, including regular one-on-ones, regular audits and performance evaluations, for direct reports.
• Identify ongoing training needs for Health Services Representatives. Assist HS Medicaid HSR trainer. Review new hire training plan and progress
• Accountable for ensuring exceptional customer service via the Health Services phone queue. Ensure related metrics are consistently met.
• Track and trend member and provider complaints. Ensure appropriate follow up. Formulate recommendations for improved service delivery and escalate/implement as indicated.
• Work collaboratively with Health Services Manager to maintain and develop departmental communication materials (i.e. letters, forms), training/educational material as well as policies and procedures.
• Actively participate in and assist with efforts to support compliance and regulatory requirements across lines of business. Participate in regular audits.
• Work collaboratively with the communication team to ensure external material is approved.
• Help to troubleshoot and resolve issues related to Health Services, escalating when appropriate.
• Ensure all coverage determinations are processed in a timely and accurate manner.
• Provide support and maintenance for department communication tools. (i.e. SharePoint)
• Coordinate business activities by maintaining collaborative partnerships with key departments.
• 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.
• Actively participate as a key team member in department, leadership and team meetings.
• Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
• Conduct regular team meetings and one-on-one meetings with the Health Service Representatives on the Health Services team.

Supporting Responsibilities:

• 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.

Work Experience: Three years of health insurance or healthcare experience required. Two years working as a Health Services Representative preferred. Previous leadership or supervisory experience preferred. Intimate familiarity with Medicaid terminology preferred.

Education, Certificates, Licenses: Minimum high school diploma or equivalent required.

Knowledge: Medical terminology, Health Insurance industry. Strong computer skills and typing. Microsoft Excel, Outlook, and Word. Proficiency in Facets and Case Trakker Dynamo and ShoreTel. Requires ability to define and prioritize problems and manage workload without direct supervision.

Competencies:

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

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.

Skills:
Accountable leadership, Collaboration, Communication (written/verbal), Critical Thinking, Decision Making, Influencing, Listening (active), Organizational skills/Planning and Organization

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.

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