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 daily operations, including supervision of Coordinators, and Specialists involved in Utilization Management (UM) functions. Responsible for delineating job assignments to team members. Accountable for team members' hiring, coaching, and performance evaluation. Establish effective leadership by endorsing teamwork, change management, cross-team collaboration, and innovation. Ensure appropriate application of services and benefits. Act as an information resource to internal and external customers. Integral involvement in the success of department initiatives and implementations.

Essential Responsibilities:

• Manage department outcomes using data, achieve PacificSource Relative Index of Service (PRISM) measures. Analyze health services utilization data to formulate recommendations for maintaining and improving the delivery of services to our members and providers.
  
• Responsible for regulatory updates to processes and reporting. Additional reports and process improvements as directed by UM & Training Coordination Leadership.
  
• Manage hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees. Provide feedback, including regular one-to-ones, regular audits and performance evaluations for direct reports.
  
• Identify ongoing training needs for Coordinators and Specialists. Meet regularly with commercial and government team leads and trainers.
  
• Accountable for providing exceptional customer service, ensuring related metrics are consistently met, and identify best practice to improve and coordinate process and customer focus.
  
• 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 and Training Team to maintain and develop departmental communication materials (e.g. letters, forms), training/educational material, and policies and procedures.
  
• Actively participate in and assist with efforts to support compliance and regulatory requirements across lines of business. Responsible for regular audits.
  
• Work collaboratively with the communication team to ensure external material is approved.
  
• Troubleshoot and resolve issues related to Health Services, escalating when appropriate.
  
• Ensure all coverage determinations are processed in a timely and accurate manner.
  
• Responsible for support and maintenance of department communication tools.
  
• Coordinate business activities by maintaining collaborative partnerships with key departments.
  
• Responsible for 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 Coordinators and Specialists 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.
  

SUCCESS PROFILE

Work Experience: A minimum of five years of experience in health insurance industry or other medical setting required. A minimum of two years of experience in a leadership, training or mentoring role required. Two years of experience in a PacificSource Health Services Department preferred. Other equivalent professional work experience may be considered.

Education, Certificates, Licenses: High school diploma or equivalent required, associate or bachelor's degree, medical assistant, licensed professional nurse, or certified professional coding certification preferred.

Knowledge: Comprehensive knowledge and understanding of the utilization management life cycle, including intersection with Care Management, UM Operations, Claims, and Appeals and Grievances. Knowledge of health plan eligibility, benefits, medical interventions and management. Ability to work independently, prioritize responsibilities, and manage demanding situations with diplomacy. Must function as a leader in a collaborative, cohesive community. Excellent oral and written communication skills. Medical terminology, computer competency, Microsoft Outlook, Word and Excel experience required. CPT/ICD coding, call tracking software, and electronic health record experience required.

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 less than 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.

This job has expired.