Location: Boise, ID
Company: Pacificsource
protected status, such as race, religion, color, national origin, interaction, interactionual orientation, gender identity or age. Diversity and Inclusion: Pacific Source 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.
Develop, coordinate, and provide employee orientation/education programs that encompass onboarding new employees as well as continuing education for all Appeals and Grievance non-clinical staff. Develop and maintain desktop references and
resource materials. Assist with creation and distribution of polices that drive the work done by the team. Assist with the organization and implementation of cross-departmental training both to train other teams on Appeals and Grievance and having internal teams present to the team.
Demonstrate effective leadership by developing teamwork, managing change, and encouraging innovation and staff involvement in the Appeals and Grievance team. Support and develop initiatives that reflect the department vision and are committed to achieving the goals and objectives of Appeals and Grievances. Essential Responsibilities: Develop, maintain, and present training programs in coordination with Appeals
and Grievance leadership and other training coordinators which ensure the Appeals and Grievance team is trained to provide exceptional customer service, meet ongoing operational and regulatory needs, and achieve quality outcomes.
Develop, organize, and maintain a centralized electronic system of standardized reference tools and training materials that reflect current practice and compliance standards both internally as well as within the broader health insurance industry. Ensure processes and resources meet regulatory compliance standards with all state and federal guidelines as well as other accrediting entities. Assist with internal audit processes on an ongoing basis.
Ensure Appeals and Grievance materials are in a state of audit readiness. Support onsite external audit efforts as needed. Ensure that each new hire has the tools to begin their new position successfully. Meet with the new employee regularly within their first 90 days of employment and at supervisor discretion thereafter to determine additional educational needs. Responsible for training and providing updates of new and revised team resource and training material to Appeals and Grievance staff. Utilize LEAN methodologies and quality improvement principles to practice and promote continuous improvement; utilize visual boards and daily huddles to monitor and communicate key performance indicators (KPI) and identify opportunities for improvement and evaluation of actions taken.
Assist employers, agents, and provider partners as indicated with questions regarding healthcare resources and procedures for employees, members and clients as indicated. Assist with the onboarding of other positions within the company that perform or help facilitate clinical decision making as needed. Supporting Responsibilities: Act as backup for other Appeals and Grievance department staff as needed and within scope of licensure.
Serve on designated committees, teams, and task groups, as directed. Represent the Appeals and Grievance department, both internally and externally, as requested by Appeals and Grievance leadership. Meet department and company performance and attendance expectations. Follow the Pacific Source privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information. Perform other duties as assigned. Work Experience: A minimum of four years of health insurance industry or medical background required, two of those years working for Pacific Source preferred.
Demonstrate an overall understanding of Appeals and Grievance processes (all lines of business). Education, Certificates, Licenses: High school degree or equivalent required. Knowledge: Microsoft Office software including Word and Excel. CPT/ICD-9 coding, call tracking software, mainframe and medical management software. Thorough knowledge of appeals and grievances for all lines of business functions. Knowledge of health plan eligibility, benefits, medical interventions, management and payment for services. Strong knowledge of medical terminology.
Ability to work under time pressure. Ability to prioritize responsibilities and to diplomatically handle demanding situations. 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 less than 25% of the time.
Skills: Accountability, Collaboration, 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.
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