Special Functions Clinician

* Join Pacific Source and help our members access quality, affordable care!
*** Pacific Source 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, sex, sexual orientation, gender identity, national origin, genetic information or age.
** Pacific Source values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

The Special Functions role is a compilation of various tasks and duties to include/but not limited to: pre, post, and focused audits, clinical component of appeals, policy preparation and review, creation of Desk Top References, compliance auditing, education, and quality event review. To accomplish these deliverables, the Special Functions Clinician will collaborate with internal partners/departments to ensure practices align with all line of business (LOB), meet the needs of our members, and adhere to regulatory requirements.
*
* Essential 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 Pacific Source 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).
** Supporting Responsibilities:
*** 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 Pacific Source 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:

** 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…