Appeals 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, 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.

The role of an Appeals Clinician is to accurately and succinctly represent the clinical component of an appeal. This is accomplished by close collaboration with external and internal partners/departments, assuring regulatory compliance, and eloquently representing the member/provider interests. Duties include but are not limited to: presenting the clinical component of appeals through thorough case review, careful research, application of policies, best practice standards, and available current, peer-reviewed information. The Appeals Clinician provides a concise summary of the appeal and represents the interests of the appealing party to the medical director for final determination.

Essential Responsibilities:

• Represent PacificSource Health Plans with external customers and maintain positive working relationships.

• Review appeal requests for appropriateness of care within established evidence-based criteria sets.

• Work with Medical Directors to facilitate appeals within established timeframes and regulatory guidelines.

• Prepare case presentations for educational purposes and collaborative efforts with each LOB.

• Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or appeal interpretation that are referred from other departments.

• Utilize Lean methodologies for continuous improvement. Utilize frequent 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.

• Collaborate with the leadership team, as well as other departments, for maintenance and accuracy of system resources

• Collect and interpret accurate claims data as needed for complete appeal review

• Ability to research and interpret various tools such as; OHA guidelines, member handbooks, provider contracts, NCCI standards, etc.

Supporting Responsibilities:

• Serve on designated committees, teams, and task groups, as directed.

• Represent the Appeals and Grievance Department, both internally and externally, as requested by Medical Director, the Appeals and Grievance Manager, and The Director of Health Services Quality Assurance and Appeals and Grievances.

• 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.

• Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: Five years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability required. Experience in acute care, case management, including cases that require rehabilitation, home health, behavioral health, and hospice treatment strongly preferred. Insurance industry experience helpful, but not required.

Education, Certificates, Licenses: Registered Nurse or Licensed Behavior Health Specialist with current unrestricted state license. Within 6 months of hire licensure may need to include Oregon, Montana, Idaho, Washington and/or other states as needed.

Knowledge: Thorough knowledge and understanding of medical and behavioral health processes, diagnoses, care modalities, procedure codes including ICD and CPT Codes, health insurance and state-mandated benefits. Understanding of contractual benefits and options available outside contractual benefits. 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. Must be able to function as part of a collaborative, cohesive community.

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

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.