PacificSource Health Plans · 1 day ago
Special Functions Clinician
Portland, OR
Full-time
Onsite
Mid Level
$71K/yr - $106K/yr
3+ years expPacificSource Health Plans is dedicated to helping members access quality, affordable care. The Special Functions Clinician is responsible for conducting audits, managing claims, and collaborating with various departments to ensure compliance with regulations and improve healthcare delivery.
CommunitiesCustomer ServiceNon Profit
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)
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
Qualification
Required
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
Must have an overall understanding of utilization management and claims costs
Registered nurse or clinically licensed behavioral health practitioner with current unrestricted state license
Ability to use computerized systems for data recording and retrieval
Assures patient confidentiality, privacy, and health records security
Ability to work independently with minimal supervision
Preferred
Insurance industry experience helpful, but not required
Project Management experience desirable
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
Company
PacificSource Health Plans
Founded in 1933, PacificSource is a not-for-profit health insurer for people and organizations throughout the Northwest.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
John Espinola MD MBA
President and CEO
Erick Doolen
Chief Operating Officer
Recent News
2025-11-29
2025-10-22
Company data provided by crunchbase