Individual Eligibility Validation Specialist
PacificSource

Job Info

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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.

Identify, track, and investigate accounts that are under coverage within our three-state region that are not residents of the area in which the coverage was obtained. Represent and manage the communication efforts with both members and providers who may interact with these accounts and provide detailed reporting that will lead to rescind decisions.

Essential Responsibilities:

• Review and prepare reporting that captures areas where misinformation may be present within the residency records of our Individual Membership.
  
• Coordinate communication with the members, brokers, and providers involved.
  
• Manage a tracking system that will allow for easy reference to open, closed, and review in progress.
  
• Review weekly, bi-weekly, and monthly reporting.
  
• Identify and analyze trends across member accounts, provider billing practices, and brokers.
  
• Participate in communication and response to identified trends across lines of business.
  
• Create and distribute regular updates to the workgroup.
  
• Use multiple tools to investigate the information included within accounts and be creative when identifying new methods of tracking information that may not be readily available in our Operating system.
  
• Generate, review, and act upon reporting at designated times to continue review and review for new risk within new cases.
  
• Track payment practices.
  
• Develop and update procedures, job aids, and best practices.
  
• Create and maintain visuals to represent the work.
  

Supporting Responsibilities:

• Meet department and company performance and attendance expectations.
  
• Participate in Escalation Board daily huddle, team and department meetings, mentor training, and team building activities.
  
• 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: Minimum three years of related experience in the health care industry required.

Education, Certificates, Licenses: Requires high school diploma or equivalent. Associate's degree in business or healthcare preferred.

Knowledge: Ability to understand and interpret state and federal insurance laws. Remain current on PacificSource procedures, policies, products, and contracts. Strong keyboarding and Excel experience required. Excellent verbal, telephone and written communication skills.

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 5% of the time.

Skills:

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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