Utilization Clinical Team Lead

Pacificsource Boise , ID 83701

Posted 2 months ago

Looking for a way to make an impact and help people?

Join PacificSource and help our members access quality, affordable care!

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.

Position Overview:

Responsible for oversight of defined Health Services programs, services, or functions which may include, but not be limited to, condition/disease management program, behavioral health services, complex care management, utilization management, grievance and appeals, claim review, and policy/procedure development. Supervises and provides guidance to direct reports and other department staff regarding company policies, procedures, and operations. Manages the quality and productivity of team responsibilities and workflow as they relate to both assigned functions and the overall effectiveness of the Health Services team. Works to resolve issues and improve processes and outcomes. Works to resolve issues and improve processes and outcomes.

Essential Responsibilities:

  • Fosters teamwork, manages change, encourages innovation, builds collaborative relationships, encourages involvement and initiative, and develops goal orientation in others..

  • Serve as liaison with other PacificSource departments and community partners to coordinate optimal provision of service and dissemination of information including regulatory updates. Serve on various internal and external committees as required or designated. Document and report any pertinent communications back to the team or department.

  • Oversee and assist in providing exceptional customer service and information to members and other external and internal customers.

  • Provide onsite and telephonic training and support with our provider community. To include collaboration with our provider network team.

  • Monitor daily workflow, volumes and other work processes of team to assure appropriate distribution and processing of tasks.

  • With the goal to improve department performance, assist with process improvement and work with other departments. Utilize LEAN methodologies for continuous improvement. Utilize visual boards to monitor key performance indicators and identify improvement opportunities.

  • Utilize and promote use and training into evidence-based medical criteria.

  • Assist with hiring and provide ongoing supervision, development, coaching, training, evaluation, and leadership of direct reports. This may include corrective actions, annual performance reviews, and involvement in promotions and/or terminations for direct reports.

  • Actively participate as a key team member in weekly meetings department, team and other meetings as assigned.

  • Work cooperatively with department leadership and staff to ensure that work processes are well-ordered and managed appropriately. Provide backup to UM staff, other departmental teams and/or management staff, as needed.

  • Facilitate investigation and resolution of process-related issues as needed. Facilitate conflict resolution, including interfacing with affected departments and individuals, as appropriate. Help to troubleshoot and resolve issues related to health services, escalating when appropriate.

  • Maintain and develop UM documents including departmental communication materials (ie. letters, forms, FAQs), training/educational material, SharePoint site and procedures.

  • Maintain excellent working knowledge of Governmental rules and regulations (including regulatory updates) to ensure that project operations remain compliant.

  • Work closely with the compliance department to ensure that utilization management activity and reporting meet the requirements of regulatory entities.

  • Participate in relevant compliance activities and audits (including resolution of gaps) and reporting as directed.

  • Actively participate in high cost and re-insurance activities.

  • Participate in review and editing Prior Authorization grid annually.

  • Monitor and evaluate team assignments relating to volumes, timelines, accuracy, customer service, and other quality and performance measures, and take appropriate actions.

Supporting Responsibilities:

  • 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.

  • Represent the Heath Services Department, both internally and externally, as requested by Health Services Manager and/or Director.

  • Perform other duties as assigned.

Work Experience: Five years clinical experience. Minimum of three years direct health plan experience in the following areas: case management, utilization management, behavioral health, and/or disease/condition management. Prior supervisory experience preferred.

Education, Certificates, Licenses: Registered nurse, Licensed Clinical psychologist, LCSW, or comparable behavioral health professional with extensive experience and/or credentials (e.g. Licensed Professional Counselor, PC, Licensed Marriage and Family Therapist LMFT, Psychiatric Mental Health Nurse Practitioner, PMHNP) with current unrestricted state license(s). Within 2 years in this position, obtain Certified Case Manager (CCM) as accredited by CCMC (The Commission for Case Management Certification) preferred, or 60 CEUs in Utilization Management areas of focus.

Knowledge:Knowledge of health insurance and state mandated benefits. Thorough knowledge and understanding of medical procedures, diagnoses, care modalities, procedure codes (including ICD-10, HCPC CPT codes), health insurance and State of Oregon mandated benefits. Effective adult education/teaching and/or group leadership skills. Ability to deal effectively with people who have various health issues and concerns. Strong analytical and organizational skills with experience in using information systems and computer applications. Is flexible. Ability to develop, review, and evaluate utilization and case management reports. Good computer skills including experience with Word, Excel, and PowerPoint. Ability to use audio-visual equipment. Ability to work independently with minimal supervision.


  • 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 5% of the time.

Our Values

  • 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 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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Utilization Clinical Team Lead