Mental Health Clinician jobs at PacificSource Health Plans - 52 jobs

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, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource 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. Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes. Clinicians incorporate the essential functions of professional case management concepts to enhance patients' quality of life and maximize health plan benefits. These functions include but are not limited to: coordination and delivery of healthcare services, consideration of physical, psychological, and cultural factors, assessment of the patient's specific health plan benefits, and additional medical, community, or financial resources available. Essential Responsibilities: Clinician Care Managers facilitate the achievement of client wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation. Collect and assess patient information pertinent to patient's history, condition, and functional abilities in order to develop a comprehensive, individualized care management plan that promotes appropriate utilization, and cost-effective care and services. Based on the needs and values of the client, and in collaboration with all service providers, the clinician links clients with appropriate providers and resources throughout the continuum of health and human services and care settings, while ensuring that the care provided is safe, effective, client-centered, timely, efficient, and equitable. Clinicians have direct communication among, the client, the payer, the primary care provider, and other service delivery professionals. The case manager is able to enhance these services by maintaining the client's privacy, confidentiality, health, and safety through advocacy and adherence to ethical, legal, accreditation, certification, and regulatory standards or guidelines. Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or contract interpretation that are referred from other departments, as well as physicians and providers of medical services and supplies. Assist employers and agents with questions regarding healthcare resources and procedures for their employees and clients. Practice and model effective communication skills: both written and verbal. Utilize and promote use of evidence-based tools. Utilize lean methodologies for continuous improvement. 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. Perform other duties as assigned. SUCCESS PROFILE Work Experience: Minimum of three (3) years of clinical experience, including case management. Insurance industry experience preferred. Education, Certificates, Licenses: Clinical Social Worker, Licensed Professional Counselor, or Licensed Independent Clinical Social Worker with unrestricted license required in current state of residence. OR Registered Nurse with current appropriate unrestricted state license based on line of business: Commercial and Medicare: Oregon, Idaho or Montana, and Washington; Medicaid and DSNP: Oregon. Certified Case Manager Certification (CCM) as accredited by CCMC (The Commission for Case Management) strongly desired at time of hire. CCM certification required within two years of hire. Knowledge: Knowledge of health insurance and state mandated benefits. Experience and expertise in case management practice including advocacy, assessment, planning, communication, education, resource management and service facilitation. Ability to deal effectively with people who have various health issues and concerns. Knowledge and understanding of contractual benefits and options available outside contractual benefits. Knowledge of community services, providers, vendors and facilities available to assist members. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. Ability to work independently with minimal supervision. 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 5% of the time. Skills: Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork Compensation Disclaimer The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range. Base Range: $70,950.00 - $106,424.99Our 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.

Capital Area Pediatrics offers accessible, comprehensive pediatric care to families at five practice locations throughout Northern Virginia. For both sickness and health, generations of families have chosen Capital Area Pediatrics to provide outstanding care and an exceptional patient experience. About the Role Capital Area Pediatrics is seeking a licensed or license-eligible therapist who has a commitment to community mental health access and who is passionate about working with children, adolescents, parents, and families. This role offers the opportunity to be at the start of an expanding behavioral health program within a private pediatric practice with five locations across Northern Virginia: Ashburn, Herndon, Vienna, Falls Church, and Sleepy Hollow. Currently seeing therapists for the Falls Church and Sleepy Hollow locations. As a Behavioral Health Therapist, you will enjoy a degree of autonomy in a flexible work environment, while delivering short-term, whole-person-centered care. Strong communication and interpersonal skills will be essential in collaborating with a team of healthcare professionals that prioritizes early intervention to provide comprehensive, integrated treatment. You will utilize your knowledge of evidence-based treatment modalities to develop and implement effective treatment plans tailored to individual needs. This is a part time position with primarily afterschool and evening hours. Essential Functions Provide individual therapy through both in person and telemedicine visits. Work with children and adolescents of all ages and backgrounds. Conduct intake assessments and safety assessments. Maintain supportive documentation through an electronic medical record. Develop and conduct psychoeducational workshops for patients and parents Be part of a collaborative team of medical and behavioral health practitioners. Participate in treatment team. Knowledge, Skills and Abilities Oral and written communication skills. Computer skills i.e. Microsoft Office suite, ability to navigate websites and experience with practice management software knowledge is preferred. Ability to travel to all site locations and work flexible hours. Ability to handle medical records discreetly. Knowledge of medical issues and terminology. Ability to multi-task and perform well in stressful situations. Strong communication skills and a customer service orientation. Time management and strong organizational skills. Can work independently and with a team. Experience and Educational Requirements Hold an active license in the state of Virginia (LCSW, LPC, LMFT) or be license-eligible. Well versed in evidence-based practice and CBT. Experience in trauma-informed care preferred. Have experience or background in child development. Capital Area Pediatrics ("the Company") is a proud Equal Opportunity Employer. We do not discriminate on the basis of race, religion, color, sex, gender identity, sexual orientation, age, non-disqualifying physical or mental disability, national origin, veteran status or any other basis covered by appropriate law. All employment decisions are based on qualifications, merit, and business needs. The Company does not accept unsolicited resumes through or from search firms or staffing agencies. All unsolicited resumes will be considered the property of the Company and the Company will not be obligated to pay a placement fee. Part Time

Job Description Capital Area Pediatrics offers accessible, comprehensive pediatric care to families at five practice locations throughout Northern Virginia. For both sickness and health, generations of families have chosen Capital Area Pediatrics to provide outstanding care and an exceptional patient experience. About the Role Capital Area Pediatrics is seeking a licensed or license-eligible therapist who has a commitment to community mental health access and who is passionate about working with children, adolescents, parents, and families. This role offers the opportunity to be at the start of an expanding behavioral health program within a private pediatric practice with five locations across Northern Virginia: Ashburn, Herndon, Vienna, Falls Church, and Sleepy Hollow. Currently seeing therapists for the Falls Church and Sleepy Hollow locations. As a Behavioral Health Therapist, you will enjoy a degree of autonomy in a flexible work environment, while delivering short-term, whole-person-centered care. Strong communication and interpersonal skills will be essential in collaborating with a team of healthcare professionals that prioritizes early intervention to provide comprehensive, integrated treatment. You will utilize your knowledge of evidence-based treatment modalities to develop and implement effective treatment plans tailored to individual needs. This is a part time position with primarily afterschool and evening hours. Essential Functions Provide individual therapy through both in person and telemedicine visits. Work with children and adolescents of all ages and backgrounds. Conduct intake assessments and safety assessments. Maintain supportive documentation through an electronic medical record. Develop and conduct psychoeducational workshops for patients and parents Be part of a collaborative team of medical and behavioral health practitioners. Participate in treatment team. Knowledge, Skills and Abilities Oral and written communication skills. Computer skills i.e. Microsoft Office suite, ability to navigate websites and experience with practice management software knowledge is preferred. Ability to travel to all site locations and work flexible hours. Ability to handle medical records discreetly. Knowledge of medical issues and terminology. Ability to multi-task and perform well in stressful situations. Strong communication skills and a customer service orientation. Time management and strong organizational skills. Can work independently and with a team. Experience and Educational Requirements Hold an active license in the state of Virginia (LCSW, LPC, LMFT) or be license-eligible. Well versed in evidence-based practice and CBT. Experience in trauma-informed care preferred. Have experience or background in child development. Capital Area Pediatrics ("the Company") is a proud Equal Opportunity Employer. We do not discriminate on the basis of race, religion, color, sex, gender identity, sexual orientation, age, non-disqualifying physical or mental disability, national origin, veteran status or any other basis covered by appropriate law. All employment decisions are based on qualifications, merit, and business needs. The Company does not accept unsolicited resumes through or from search firms or staffing agencies. All unsolicited resumes will be considered the property of the Company and the Company will not be obligated to pay a placement fee. Part Time

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, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource 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 role of an Appeals Clinician is to accurately and succinctly represent the clinical component of an appeal. This is accomplished by close collaboration with external and internal partners/departments, assuring regulatory compliance, and eloquently representing the member/provider interests. Duties include but are not limited to: presenting the clinical component of appeals through thorough case review, careful research, application of policies, best practice standards, and available current, peer-reviewed information. The Appeals Clinician provides a concise summary of the appeal and represents the interests of the appealing party to the medical director for final determination. Essential Responsibilities: Represent PacificSource Health Plans with external customers and maintain positive working relationships. Review appeal requests for appropriateness of care within established evidence-based criteria sets. Work with Medical Directors to facilitate appeals within established timeframes and regulatory guidelines. Prepare case presentations for educational purposes and collaborative efforts with each LOB. Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or appeal interpretation that are referred from other departments. Utilize Lean methodologies for continuous improvement. Utilize frequent 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. Collaborate with the leadership team, as well as other departments, for maintenance and accuracy of system resources Collect and interpret accurate claims data as needed for complete appeal review Ability to research and interpret various tools such as; OHA guidelines, member handbooks, provider contracts, NCCI standards, etc. Supporting Responsibilities: Serve on designated committees, teams, and task groups, as directed. Represent the Appeals and Grievance Department, both internally and externally, as requested by Medical Director, the Appeals and Grievance Manager, and The Director of Health Services Quality Assurance and Appeals and Grievances. 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. Perform other duties as assigned. SUCCESS PROFILE Work Experience: Minimum of three (3) years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability required. Experience in acute care, case management, including cases that require rehabilitation, home health, behavioral health, and hospice treatment strongly preferred. Insurance industry experience helpful, but not required. Education, Certificates, Licenses: Registered Nurse or licensed behavior health specialist with current unrestricted state license. Within six (6) months of hire, licensure may need to include Oregon, Montana, Idaho, Washington and/or other states as needed. Knowledge: Thorough knowledge and understanding of medical and behavioral health processes, diagnoses, care modalities, procedure codes including ICD and CPT Codes, health insurance and state-mandated benefits. Understanding of contractual benefits and options available outside contractual benefits. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. 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 5% of the time. Skills: Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork Compensation Disclaimer The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range. Base Range: $70,950.00 - $106,424.99Our 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.

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, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource 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 role of an Appeals Clinician is to accurately and succinctly represent the clinical component of an appeal. This is accomplished by close collaboration with external and internal partners/departments, assuring regulatory compliance, and eloquently representing the member/provider interests. Duties include but are not limited to: presenting the clinical component of appeals through thorough case review, careful research, application of policies, best practice standards, and available current, peer-reviewed information. The Appeals Clinician provides a concise summary of the appeal and represents the interests of the appealing party to the medical director for final determination. Essential Responsibilities: Represent PacificSource Health Plans with external customers and maintain positive working relationships. Review appeal requests for appropriateness of care within established evidence-based criteria sets. Work with Medical Directors to facilitate appeals within established timeframes and regulatory guidelines. Prepare case presentations for educational purposes and collaborative efforts with each LOB. Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or appeal interpretation that are referred from other departments. Utilize Lean methodologies for continuous improvement. Utilize frequent 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. Collaborate with the leadership team, as well as other departments, for maintenance and accuracy of system resources Collect and interpret accurate claims data as needed for complete appeal review Ability to research and interpret various tools such as; OHA guidelines, member handbooks, provider contracts, NCCI standards, etc. Supporting Responsibilities: Serve on designated committees, teams, and task groups, as directed. Represent the Appeals and Grievance Department, both internally and externally, as requested by Medical Director, the Appeals and Grievance Manager, and The Director of Health Services Quality Assurance and Appeals and Grievances. 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. Perform other duties as assigned. SUCCESS PROFILE Work Experience: Minimum of three (3) years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability required. Experience in acute care, case management, including cases that require rehabilitation, home health, behavioral health, and hospice treatment strongly preferred. Insurance industry experience helpful, but not required. Education, Certificates, Licenses: Registered Nurse or licensed behavior health specialist with current unrestricted state license. Within six (6) months of hire, licensure may need to include Oregon, Montana, Idaho, Washington and/or other states as needed. Knowledge: Thorough knowledge and understanding of medical and behavioral health processes, diagnoses, care modalities, procedure codes including ICD and CPT Codes, health insurance and state-mandated benefits. Understanding of contractual benefits and options available outside contractual benefits. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. 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 5% of the time. Skills: Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork Compensation Disclaimer The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range. Base Range: $70,950.00 - $106,424.99Our 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.

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, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource 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. Collaborate closely with physicians, nurses, social workers and a wide range of medical and non-medical professionals to coordinate delivery of healthcare services. Assess the member's specific health plan benefits and the additional medical, community, or financial resources available. Provide utilization management (UM) services which promote quality, cost-effective outcomes by helping member populations achieve effective utilization of healthcare services. Facilitate outstanding member care using fiscally responsible strategies. Essential Responsibilities: * Collect and assess member information pertinent to member's history, condition, and functional abilities in order to promote wellness, appropriate utilization, and cost-effective care and services. * Coordinate necessary resources to achieve member outcome goals and objectives. * Accurately document case notes and letters of explanation which may become part of legal records. * Perform concurrent review of members admitted to inpatient facilities, residential treatment centers, and partial hospitalization programs. * Maintain contact with the inpatient facility utilization review personnel to assure appropriateness of continued stay and level of care. * Identify cases that require discharge planning, including transfer to skilled nursing facilities, rehabilitation centers, residential, and outpatient to include behavioral health, home health, and hospice services while considering member co-morbid conditions. * Review referral and preauthorization requests for appropriateness of care within established evidence-based criteria sets. * When applicable, identify and negotiate with appropriate vendors to provide services. * When appropriate, negotiate discounts with non-contracted providers and/or refer such providers to Provider Network Department for contract development. * Work with multidisciplinary teams utilizing an integrated team-based approach to best support members, which may include working together on network not available (NNA), out of network exceptions (OONE), and one-time agreements (OTA). * Serve as primary resource to member and family members for questions and concerns related to the health plan and in navigating through the health systems issues. * Interact with other PacificSource personnel to assure quality customer service is provided. * Act as an internal resource by answering questions requiring medical or contract interpretation that are referred from other departments, as well as physicians and providers of medical services and supplies. * Assist employers and agents with questions regarding healthcare resources and procedures for their employees and clients. * Identify high cost utilization and refer to Large Case Reinsurance RN and Care Management team as appropriate. * Assist Medical Director in developing guidelines and procedures for Health Services Department. Supporting Responsibilities: * Act as backup and be a resource for other Health Services Department staff and functions as needed. * Serve on designated committees, teams, and task groups, as directed. * Represent the Heath Services Department, both internally and externally, as requested by Medical Director. * 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. * Perform other duties as assigned. SUCCESS PROFILE Work Experience: Minimum of three (3) years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability required. Experience in acute care, case management, including cases that require rehabilitation, home health, behavioral health and hospice treatment strongly preferred. Insurance industry experience helpful, but not required. Education, Certificates, Licenses: Registered Nurse or a clinically licensed behavioral health practitioner with current unrestricted state license. Within six (6) months of hire licensure may need to include Oregon, Montana, Idaho and/or other states as needed. Case Manager Certification as accredited by CCMC preferred. Knowledge: Thorough knowledge and understanding of medical and behavioral health processes, diagnoses, care modalities, procedure codes including ICD and CPT Codes, health insurance and state-mandated benefits. Understanding of contractual benefits and options available outside contractual benefits. Working knowledge of community services, providers, vendors and facilities available to assist members. Understanding of appropriate case management plans. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. 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 5% 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.

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, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource 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. Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes. Clinicians incorporate the essential functions of professional case management concepts to enhance patients' quality of life and maximize health plan benefits. These functions include but are not limited to: coordination and delivery of healthcare services, consideration of physical, psychological, and cultural factors, assessment of the patient's specific health plan benefits, and additional medical, community, or financial resources available. Essential Responsibilities: Clinician Care Managers facilitate the achievement of client wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation. Collect and assess patient information pertinent to patient's history, condition, and functional abilities in order to develop a comprehensive, individualized care management plan that promotes appropriate utilization, and cost-effective care and services. Based on the needs and values of the client, and in collaboration with all service providers, the clinician links clients with appropriate providers and resources throughout the continuum of health and human services and care settings, while ensuring that the care provided is safe, effective, client-centered, timely, efficient, and equitable. Clinicians have direct communication among, the client, the payer, the primary care provider, and other service delivery professionals. The case manager is able to enhance these services by maintaining the client's privacy, confidentiality, health, and safety through advocacy and adherence to ethical, legal, accreditation, certification, and regulatory standards or guidelines. Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or contract interpretation that are referred from other departments, as well as physicians and providers of medical services and supplies. Assist employers and agents with questions regarding healthcare resources and procedures for their employees and clients. Practice and model effective communication skills: both written and verbal. Utilize and promote use of evidence-based tools. Utilize lean methodologies for continuous improvement. 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. Perform other duties as assigned. SUCCESS PROFILE Work Experience: Minimum of three (3) years of clinical experience, including case management. Insurance industry experience preferred. Education, Certificates, Licenses: Clinical Social Worker, Licensed Professional Counselor, or Licensed Independent Clinical Social Worker with unrestricted license required in current state of residence. OR Registered Nurse with current appropriate unrestricted state license based on line of business: Commercial and Medicare: Oregon, Idaho or Montana, and Washington; Medicaid and DSNP: Oregon. Certified Case Manager Certification (CCM) as accredited by CCMC (The Commission for Case Management) strongly desired at time of hire. CCM certification required within two years of hire. Knowledge: Knowledge of health insurance and state mandated benefits. Experience and expertise in case management practice including advocacy, assessment, planning, communication, education, resource management and service facilitation. Ability to deal effectively with people who have various health issues and concerns. Knowledge and understanding of contractual benefits and options available outside contractual benefits. Knowledge of community services, providers, vendors and facilities available to assist members. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. Ability to work independently with minimal supervision. 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 5% of the time. Skills: Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork Compensation Disclaimer The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range. Base Range: $70,950.00 - $106,424.99Our 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.

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, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource 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 role of an Appeals Clinician is to accurately and succinctly represent the clinical component of an appeal. This is accomplished by close collaboration with external and internal partners/departments, assuring regulatory compliance, and eloquently representing the member/provider interests. Duties include but are not limited to: presenting the clinical component of appeals through thorough case review, careful research, application of policies, best practice standards, and available current, peer-reviewed information. The Appeals Clinician provides a concise summary of the appeal and represents the interests of the appealing party to the medical director for final determination. Essential Responsibilities: Represent PacificSource Health Plans with external customers and maintain positive working relationships. Review appeal requests for appropriateness of care within established evidence-based criteria sets. Work with Medical Directors to facilitate appeals within established timeframes and regulatory guidelines. Prepare case presentations for educational purposes and collaborative efforts with each LOB. Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or appeal interpretation that are referred from other departments. Utilize Lean methodologies for continuous improvement. Utilize frequent 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. Collaborate with the leadership team, as well as other departments, for maintenance and accuracy of system resources Collect and interpret accurate claims data as needed for complete appeal review Ability to research and interpret various tools such as; OHA guidelines, member handbooks, provider contracts, NCCI standards, etc. Supporting Responsibilities: Serve on designated committees, teams, and task groups, as directed. Represent the Appeals and Grievance Department, both internally and externally, as requested by Medical Director, the Appeals and Grievance Manager, and The Director of Health Services Quality Assurance and Appeals and Grievances. 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. Perform other duties as assigned. SUCCESS PROFILE Work Experience: Minimum of three (3) years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability required. Experience in acute care, case management, including cases that require rehabilitation, home health, behavioral health, and hospice treatment strongly preferred. Insurance industry experience helpful, but not required. Education, Certificates, Licenses: Registered Nurse or licensed behavior health specialist with current unrestricted state license. Within six (6) months of hire, licensure may need to include Oregon, Montana, Idaho, Washington and/or other states as needed. Knowledge: Thorough knowledge and understanding of medical and behavioral health processes, diagnoses, care modalities, procedure codes including ICD and CPT Codes, health insurance and state-mandated benefits. Understanding of contractual benefits and options available outside contractual benefits. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. 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 5% of the time. Skills: Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork Compensation Disclaimer The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range. Base Range: $70,950.00 - $106,424.99Our 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.

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, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource 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. Collaborate closely with physicians, nurses, social workers and a wide range of medical and non-medical professionals to coordinate delivery of healthcare services. Assess the member's specific health plan benefits and the additional medical, community, or financial resources available. Provide utilization management (UM) services which promote quality, cost-effective outcomes by helping member populations achieve effective utilization of healthcare services. Facilitate outstanding member care using fiscally responsible strategies. Essential Responsibilities: * Collect and assess member information pertinent to member's history, condition, and functional abilities in order to promote wellness, appropriate utilization, and cost-effective care and services. * Coordinate necessary resources to achieve member outcome goals and objectives. * Accurately document case notes and letters of explanation which may become part of legal records. * Perform concurrent review of members admitted to inpatient facilities, residential treatment centers, and partial hospitalization programs. * Maintain contact with the inpatient facility utilization review personnel to assure appropriateness of continued stay and level of care. * Identify cases that require discharge planning, including transfer to skilled nursing facilities, rehabilitation centers, residential, and outpatient to include behavioral health, home health, and hospice services while considering member co-morbid conditions. * Review referral and preauthorization requests for appropriateness of care within established evidence-based criteria sets. * When applicable, identify and negotiate with appropriate vendors to provide services. * When appropriate, negotiate discounts with non-contracted providers and/or refer such providers to Provider Network Department for contract development. * Work with multidisciplinary teams utilizing an integrated team-based approach to best support members, which may include working together on network not available (NNA), out of network exceptions (OONE), and one-time agreements (OTA). * Serve as primary resource to member and family members for questions and concerns related to the health plan and in navigating through the health systems issues. * Interact with other PacificSource personnel to assure quality customer service is provided. * Act as an internal resource by answering questions requiring medical or contract interpretation that are referred from other departments, as well as physicians and providers of medical services and supplies. * Assist employers and agents with questions regarding healthcare resources and procedures for their employees and clients. * Identify high cost utilization and refer to Large Case Reinsurance RN and Care Management team as appropriate. * Assist Medical Director in developing guidelines and procedures for Health Services Department. Supporting Responsibilities: * Act as backup and be a resource for other Health Services Department staff and functions as needed. * Serve on designated committees, teams, and task groups, as directed. * Represent the Heath Services Department, both internally and externally, as requested by Medical Director. * 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. * Perform other duties as assigned. SUCCESS PROFILE Work Experience: Minimum of three (3) years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability required. Experience in acute care, case management, including cases that require rehabilitation, home health, behavioral health and hospice treatment strongly preferred. Insurance industry experience helpful, but not required. Education, Certificates, Licenses: Registered Nurse or a clinically licensed behavioral health practitioner with current unrestricted state license. Within six (6) months of hire licensure may need to include Oregon, Montana, Idaho and/or other states as needed. Case Manager Certification as accredited by CCMC preferred. Knowledge: Thorough knowledge and understanding of medical and behavioral health processes, diagnoses, care modalities, procedure codes including ICD and CPT Codes, health insurance and state-mandated benefits. Understanding of contractual benefits and options available outside contractual benefits. Working knowledge of community services, providers, vendors and facilities available to assist members. Understanding of appropriate case management plans. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. 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 5% 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.

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, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource 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. Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes. Clinicians incorporate the essential functions of professional case management concepts to enhance patients' quality of life and maximize health plan benefits. These functions include but are not limited to: coordination and delivery of healthcare services, consideration of physical, psychological, and cultural factors, assessment of the patient's specific health plan benefits, and additional medical, community, or financial resources available. Essential Responsibilities: Clinician Care Managers facilitate the achievement of client wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation. Collect and assess patient information pertinent to patient's history, condition, and functional abilities in order to develop a comprehensive, individualized care management plan that promotes appropriate utilization, and cost-effective care and services. Based on the needs and values of the client, and in collaboration with all service providers, the clinician links clients with appropriate providers and resources throughout the continuum of health and human services and care settings, while ensuring that the care provided is safe, effective, client-centered, timely, efficient, and equitable. Clinicians have direct communication among, the client, the payer, the primary care provider, and other service delivery professionals. The case manager is able to enhance these services by maintaining the client's privacy, confidentiality, health, and safety through advocacy and adherence to ethical, legal, accreditation, certification, and regulatory standards or guidelines. Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or contract interpretation that are referred from other departments, as well as physicians and providers of medical services and supplies. Assist employers and agents with questions regarding healthcare resources and procedures for their employees and clients. Practice and model effective communication skills: both written and verbal. Utilize and promote use of evidence-based tools. Utilize lean methodologies for continuous improvement. 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. Perform other duties as assigned. SUCCESS PROFILE Work Experience: Minimum of three (3) years of clinical experience, including case management. Insurance industry experience preferred. Education, Certificates, Licenses: Clinical Social Worker, Licensed Professional Counselor, or Licensed Independent Clinical Social Worker with unrestricted license required in current state of residence. OR Registered Nurse with current appropriate unrestricted state license based on line of business: Commercial and Medicare: Oregon, Idaho or Montana, and Washington; Medicaid and DSNP: Oregon. Certified Case Manager Certification (CCM) as accredited by CCMC (The Commission for Case Management) strongly desired at time of hire. CCM certification required within two years of hire. Knowledge: Knowledge of health insurance and state mandated benefits. Experience and expertise in case management practice including advocacy, assessment, planning, communication, education, resource management and service facilitation. Ability to deal effectively with people who have various health issues and concerns. Knowledge and understanding of contractual benefits and options available outside contractual benefits. Knowledge of community services, providers, vendors and facilities available to assist members. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. Ability to work independently with minimal supervision. 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 5% of the time. Skills: Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork Compensation Disclaimer The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range. Base Range: $70,950.00 - $106,424.99Our 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.

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, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource 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. Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes. Clinicians incorporate the essential functions of professional case management concepts to enhance patients' quality of life and maximize health plan benefits. These functions include but are not limited to: coordination and delivery of healthcare services, consideration of physical, psychological, and cultural factors, assessment of the patient's specific health plan benefits, and additional medical, community, or financial resources available. Essential Responsibilities: Clinician Care Managers facilitate the achievement of client wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation. Collect and assess patient information pertinent to patient's history, condition, and functional abilities in order to develop a comprehensive, individualized care management plan that promotes appropriate utilization, and cost-effective care and services. Based on the needs and values of the client, and in collaboration with all service providers, the clinician links clients with appropriate providers and resources throughout the continuum of health and human services and care settings, while ensuring that the care provided is safe, effective, client-centered, timely, efficient, and equitable. Clinicians have direct communication among, the client, the payer, the primary care provider, and other service delivery professionals. The case manager is able to enhance these services by maintaining the client's privacy, confidentiality, health, and safety through advocacy and adherence to ethical, legal, accreditation, certification, and regulatory standards or guidelines. Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or contract interpretation that are referred from other departments, as well as physicians and providers of medical services and supplies. Assist employers and agents with questions regarding healthcare resources and procedures for their employees and clients. Practice and model effective communication skills: both written and verbal. Utilize and promote use of evidence-based tools. Utilize lean methodologies for continuous improvement. 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. Perform other duties as assigned. SUCCESS PROFILE Work Experience: Minimum of three (3) years of clinical experience, including case management. Insurance industry experience preferred. Education, Certificates, Licenses: Clinical Social Worker, Licensed Professional Counselor, or Licensed Independent Clinical Social Worker with unrestricted license required in current state of residence. OR Registered Nurse with current appropriate unrestricted state license based on line of business: Commercial and Medicare: Oregon, Idaho or Montana, and Washington; Medicaid and DSNP: Oregon. Certified Case Manager Certification (CCM) as accredited by CCMC (The Commission for Case Management) strongly desired at time of hire. CCM certification required within two years of hire. Knowledge: Knowledge of health insurance and state mandated benefits. Experience and expertise in case management practice including advocacy, assessment, planning, communication, education, resource management and service facilitation. Ability to deal effectively with people who have various health issues and concerns. Knowledge and understanding of contractual benefits and options available outside contractual benefits. Knowledge of community services, providers, vendors and facilities available to assist members. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. Ability to work independently with minimal supervision. 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 5% of the time. Skills: Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork Compensation Disclaimer The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range. Base Range: $70,950.00 - $106,424.99Our 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.

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, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource 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 role of an Appeals Clinician is to accurately and succinctly represent the clinical component of an appeal. This is accomplished by close collaboration with external and internal partners/departments, assuring regulatory compliance, and eloquently representing the member/provider interests. Duties include but are not limited to: presenting the clinical component of appeals through thorough case review, careful research, application of policies, best practice standards, and available current, peer-reviewed information. The Appeals Clinician provides a concise summary of the appeal and represents the interests of the appealing party to the medical director for final determination. Essential Responsibilities: Represent PacificSource Health Plans with external customers and maintain positive working relationships. Review appeal requests for appropriateness of care within established evidence-based criteria sets. Work with Medical Directors to facilitate appeals within established timeframes and regulatory guidelines. Prepare case presentations for educational purposes and collaborative efforts with each LOB. Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or appeal interpretation that are referred from other departments. Utilize Lean methodologies for continuous improvement. Utilize frequent 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. Collaborate with the leadership team, as well as other departments, for maintenance and accuracy of system resources Collect and interpret accurate claims data as needed for complete appeal review Ability to research and interpret various tools such as; OHA guidelines, member handbooks, provider contracts, NCCI standards, etc. Supporting Responsibilities: Serve on designated committees, teams, and task groups, as directed. Represent the Appeals and Grievance Department, both internally and externally, as requested by Medical Director, the Appeals and Grievance Manager, and The Director of Health Services Quality Assurance and Appeals and Grievances. 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. Perform other duties as assigned. SUCCESS PROFILE Work Experience: Minimum of three (3) years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability required. Experience in acute care, case management, including cases that require rehabilitation, home health, behavioral health, and hospice treatment strongly preferred. Insurance industry experience helpful, but not required. Education, Certificates, Licenses: Registered Nurse or licensed behavior health specialist with current unrestricted state license. Within six (6) months of hire, licensure may need to include Oregon, Montana, Idaho, Washington and/or other states as needed. Knowledge: Thorough knowledge and understanding of medical and behavioral health processes, diagnoses, care modalities, procedure codes including ICD and CPT Codes, health insurance and state-mandated benefits. Understanding of contractual benefits and options available outside contractual benefits. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. 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 5% of the time. Skills: Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork Compensation Disclaimer The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range. Base Range: $70,950.00 - $106,424.99Our 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.

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, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource 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. Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes. Clinicians incorporate the essential functions of professional case management concepts to enhance patients' quality of life and maximize health plan benefits. These functions include but are not limited to: coordination and delivery of healthcare services, consideration of physical, psychological, and cultural factors, assessment of the patient's specific health plan benefits, and additional medical, community, or financial resources available. Essential Responsibilities: Clinician Care Managers facilitate the achievement of client wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation. Collect and assess patient information pertinent to patient's history, condition, and functional abilities in order to develop a comprehensive, individualized care management plan that promotes appropriate utilization, and cost-effective care and services. Based on the needs and values of the client, and in collaboration with all service providers, the clinician links clients with appropriate providers and resources throughout the continuum of health and human services and care settings, while ensuring that the care provided is safe, effective, client-centered, timely, efficient, and equitable. Clinicians have direct communication among, the client, the payer, the primary care provider, and other service delivery professionals. The case manager is able to enhance these services by maintaining the client's privacy, confidentiality, health, and safety through advocacy and adherence to ethical, legal, accreditation, certification, and regulatory standards or guidelines. Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or contract interpretation that are referred from other departments, as well as physicians and providers of medical services and supplies. Assist employers and agents with questions regarding healthcare resources and procedures for their employees and clients. Practice and model effective communication skills: both written and verbal. Utilize and promote use of evidence-based tools. Utilize lean methodologies for continuous improvement. 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. Perform other duties as assigned. SUCCESS PROFILE Work Experience: Minimum of three (3) years of clinical experience, including case management. Insurance industry experience preferred. Education, Certificates, Licenses: Clinical Social Worker, Licensed Professional Counselor, or Licensed Independent Clinical Social Worker with unrestricted license required in current state of residence. OR Registered Nurse with current appropriate unrestricted state license based on line of business: Commercial and Medicare: Oregon, Idaho or Montana, and Washington; Medicaid and DSNP: Oregon. Certified Case Manager Certification (CCM) as accredited by CCMC (The Commission for Case Management) strongly desired at time of hire. CCM certification required within two years of hire. Knowledge: Knowledge of health insurance and state mandated benefits. Experience and expertise in case management practice including advocacy, assessment, planning, communication, education, resource management and service facilitation. Ability to deal effectively with people who have various health issues and concerns. Knowledge and understanding of contractual benefits and options available outside contractual benefits. Knowledge of community services, providers, vendors and facilities available to assist members. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. Ability to work independently with minimal supervision. 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 5% of the time. Skills: Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork Compensation Disclaimer The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range. Base Range: $70,950.00 - $106,424.99Our 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.

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, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource 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 role of an Appeals Clinician is to accurately and succinctly represent the clinical component of an appeal. This is accomplished by close collaboration with external and internal partners/departments, assuring regulatory compliance, and eloquently representing the member/provider interests. Duties include but are not limited to: presenting the clinical component of appeals through thorough case review, careful research, application of policies, best practice standards, and available current, peer-reviewed information. The Appeals Clinician provides a concise summary of the appeal and represents the interests of the appealing party to the medical director for final determination. Essential Responsibilities: Represent PacificSource Health Plans with external customers and maintain positive working relationships. Review appeal requests for appropriateness of care within established evidence-based criteria sets. Work with Medical Directors to facilitate appeals within established timeframes and regulatory guidelines. Prepare case presentations for educational purposes and collaborative efforts with each LOB. Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or appeal interpretation that are referred from other departments. Utilize Lean methodologies for continuous improvement. Utilize frequent 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. Collaborate with the leadership team, as well as other departments, for maintenance and accuracy of system resources Collect and interpret accurate claims data as needed for complete appeal review Ability to research and interpret various tools such as; OHA guidelines, member handbooks, provider contracts, NCCI standards, etc. Supporting Responsibilities: Serve on designated committees, teams, and task groups, as directed. Represent the Appeals and Grievance Department, both internally and externally, as requested by Medical Director, the Appeals and Grievance Manager, and The Director of Health Services Quality Assurance and Appeals and Grievances. 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. Perform other duties as assigned. SUCCESS PROFILE Work Experience: Minimum of three (3) years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability required. Experience in acute care, case management, including cases that require rehabilitation, home health, behavioral health, and hospice treatment strongly preferred. Insurance industry experience helpful, but not required. Education, Certificates, Licenses: Registered Nurse or licensed behavior health specialist with current unrestricted state license. Within six (6) months of hire, licensure may need to include Oregon, Montana, Idaho, Washington and/or other states as needed. Knowledge: Thorough knowledge and understanding of medical and behavioral health processes, diagnoses, care modalities, procedure codes including ICD and CPT Codes, health insurance and state-mandated benefits. Understanding of contractual benefits and options available outside contractual benefits. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. 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 5% of the time. Skills: Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork Compensation Disclaimer The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range. Base Range: $70,950.00 - $106,424.99Our 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.

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, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource 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. Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes. Clinicians incorporate the essential functions of professional case management concepts to enhance patients' quality of life and maximize health plan benefits. These functions include but are not limited to: coordination and delivery of healthcare services, consideration of physical, psychological, and cultural factors, assessment of the patient's specific health plan benefits, and additional medical, community, or financial resources available. Essential Responsibilities: Clinician Care Managers facilitate the achievement of client wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation. Collect and assess patient information pertinent to patient's history, condition, and functional abilities in order to develop a comprehensive, individualized care management plan that promotes appropriate utilization, and cost-effective care and services. Based on the needs and values of the client, and in collaboration with all service providers, the clinician links clients with appropriate providers and resources throughout the continuum of health and human services and care settings, while ensuring that the care provided is safe, effective, client-centered, timely, efficient, and equitable. Clinicians have direct communication among, the client, the payer, the primary care provider, and other service delivery professionals. The case manager is able to enhance these services by maintaining the client's privacy, confidentiality, health, and safety through advocacy and adherence to ethical, legal, accreditation, certification, and regulatory standards or guidelines. Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or contract interpretation that are referred from other departments, as well as physicians and providers of medical services and supplies. Assist employers and agents with questions regarding healthcare resources and procedures for their employees and clients. Practice and model effective communication skills: both written and verbal. Utilize and promote use of evidence-based tools. Utilize lean methodologies for continuous improvement. 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. Perform other duties as assigned. SUCCESS PROFILE Work Experience: Minimum of three (3) years of clinical experience, including case management. Insurance industry experience preferred. Education, Certificates, Licenses: Clinical Social Worker, Licensed Professional Counselor, or Licensed Independent Clinical Social Worker with unrestricted license required in current state of residence. OR Registered Nurse with current appropriate unrestricted state license based on line of business: Commercial and Medicare: Oregon, Idaho or Montana, and Washington; Medicaid and DSNP: Oregon. Certified Case Manager Certification (CCM) as accredited by CCMC (The Commission for Case Management) strongly desired at time of hire. CCM certification required within two years of hire. Knowledge: Knowledge of health insurance and state mandated benefits. Experience and expertise in case management practice including advocacy, assessment, planning, communication, education, resource management and service facilitation. Ability to deal effectively with people who have various health issues and concerns. Knowledge and understanding of contractual benefits and options available outside contractual benefits. Knowledge of community services, providers, vendors and facilities available to assist members. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. Ability to work independently with minimal supervision. 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 5% of the time. Skills: Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork Compensation Disclaimer The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range. Base Range: $70,950.00 - $106,424.99Our 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.

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, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource 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 role of an Appeals Clinician is to accurately and succinctly represent the clinical component of an appeal. This is accomplished by close collaboration with external and internal partners/departments, assuring regulatory compliance, and eloquently representing the member/provider interests. Duties include but are not limited to: presenting the clinical component of appeals through thorough case review, careful research, application of policies, best practice standards, and available current, peer-reviewed information. The Appeals Clinician provides a concise summary of the appeal and represents the interests of the appealing party to the medical director for final determination. Essential Responsibilities: Represent PacificSource Health Plans with external customers and maintain positive working relationships. Review appeal requests for appropriateness of care within established evidence-based criteria sets. Work with Medical Directors to facilitate appeals within established timeframes and regulatory guidelines. Prepare case presentations for educational purposes and collaborative efforts with each LOB. Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or appeal interpretation that are referred from other departments. Utilize Lean methodologies for continuous improvement. Utilize frequent 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. Collaborate with the leadership team, as well as other departments, for maintenance and accuracy of system resources Collect and interpret accurate claims data as needed for complete appeal review Ability to research and interpret various tools such as; OHA guidelines, member handbooks, provider contracts, NCCI standards, etc. Supporting Responsibilities: Serve on designated committees, teams, and task groups, as directed. Represent the Appeals and Grievance Department, both internally and externally, as requested by Medical Director, the Appeals and Grievance Manager, and The Director of Health Services Quality Assurance and Appeals and Grievances. 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. Perform other duties as assigned. SUCCESS PROFILE Work Experience: Minimum of three (3) years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability required. Experience in acute care, case management, including cases that require rehabilitation, home health, behavioral health, and hospice treatment strongly preferred. Insurance industry experience helpful, but not required. Education, Certificates, Licenses: Registered Nurse or licensed behavior health specialist with current unrestricted state license. Within six (6) months of hire, licensure may need to include Oregon, Montana, Idaho, Washington and/or other states as needed. Knowledge: Thorough knowledge and understanding of medical and behavioral health processes, diagnoses, care modalities, procedure codes including ICD and CPT Codes, health insurance and state-mandated benefits. Understanding of contractual benefits and options available outside contractual benefits. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. 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 5% of the time. Skills: Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork Compensation Disclaimer The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range. Base Range: $70,950.00 - $106,424.99Our 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.

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, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource 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. Collaborate closely with physicians, nurses, social workers and a wide range of medical and non-medical professionals to coordinate delivery of healthcare services. Assess the member's specific health plan benefits and the additional medical, community, or financial resources available. Provide utilization management (UM) services which promote quality, cost-effective outcomes by helping member populations achieve effective utilization of healthcare services. Facilitate outstanding member care using fiscally responsible strategies. Essential Responsibilities: * Collect and assess member information pertinent to member's history, condition, and functional abilities in order to promote wellness, appropriate utilization, and cost-effective care and services. * Coordinate necessary resources to achieve member outcome goals and objectives. * Accurately document case notes and letters of explanation which may become part of legal records. * Perform concurrent review of members admitted to inpatient facilities, residential treatment centers, and partial hospitalization programs. * Maintain contact with the inpatient facility utilization review personnel to assure appropriateness of continued stay and level of care. * Identify cases that require discharge planning, including transfer to skilled nursing facilities, rehabilitation centers, residential, and outpatient to include behavioral health, home health, and hospice services while considering member co-morbid conditions. * Review referral and preauthorization requests for appropriateness of care within established evidence-based criteria sets. * When applicable, identify and negotiate with appropriate vendors to provide services. * When appropriate, negotiate discounts with non-contracted providers and/or refer such providers to Provider Network Department for contract development. * Work with multidisciplinary teams utilizing an integrated team-based approach to best support members, which may include working together on network not available (NNA), out of network exceptions (OONE), and one-time agreements (OTA). * Serve as primary resource to member and family members for questions and concerns related to the health plan and in navigating through the health systems issues. * Interact with other PacificSource personnel to assure quality customer service is provided. * Act as an internal resource by answering questions requiring medical or contract interpretation that are referred from other departments, as well as physicians and providers of medical services and supplies. * Assist employers and agents with questions regarding healthcare resources and procedures for their employees and clients. * Identify high cost utilization and refer to Large Case Reinsurance RN and Care Management team as appropriate. * Assist Medical Director in developing guidelines and procedures for Health Services Department. Supporting Responsibilities: * Act as backup and be a resource for other Health Services Department staff and functions as needed. * Serve on designated committees, teams, and task groups, as directed. * Represent the Heath Services Department, both internally and externally, as requested by Medical Director. * 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. * Perform other duties as assigned. SUCCESS PROFILE Work Experience: Minimum of three (3) years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability required. Experience in acute care, case management, including cases that require rehabilitation, home health, behavioral health and hospice treatment strongly preferred. Insurance industry experience helpful, but not required. Education, Certificates, Licenses: Registered Nurse or a clinically licensed behavioral health practitioner with current unrestricted state license. Within six (6) months of hire licensure may need to include Oregon, Montana, Idaho and/or other states as needed. Case Manager Certification as accredited by CCMC preferred. Knowledge: Thorough knowledge and understanding of medical and behavioral health processes, diagnoses, care modalities, procedure codes including ICD and CPT Codes, health insurance and state-mandated benefits. Understanding of contractual benefits and options available outside contractual benefits. Working knowledge of community services, providers, vendors and facilities available to assist members. Understanding of appropriate case management plans. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. 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 5% 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.

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, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource 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. Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the client's health and human service needs. It is characterized by advocacy, communication, and resource management and promotes quality and cost-effective interventions and outcomes. Clinicians incorporate the essential functions of professional case management concepts to enhance patients' quality of life and maximize health plan benefits. These functions include but are not limited to: coordination and delivery of healthcare services, consideration of physical, psychological, and cultural factors, assessment of the patient's specific health plan benefits, and additional medical, community, or financial resources available. Essential Responsibilities: Clinician Care Managers facilitate the achievement of client wellness and autonomy through advocacy, assessment, planning, communication, education, resource management, and service facilitation. Collect and assess patient information pertinent to patient's history, condition, and functional abilities in order to develop a comprehensive, individualized care management plan that promotes appropriate utilization, and cost-effective care and services. Based on the needs and values of the client, and in collaboration with all service providers, the clinician links clients with appropriate providers and resources throughout the continuum of health and human services and care settings, while ensuring that the care provided is safe, effective, client-centered, timely, efficient, and equitable. Clinicians have direct communication among, the client, the payer, the primary care provider, and other service delivery professionals. The case manager is able to enhance these services by maintaining the client's privacy, confidentiality, health, and safety through advocacy and adherence to ethical, legal, accreditation, certification, and regulatory standards or guidelines. Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or contract interpretation that are referred from other departments, as well as physicians and providers of medical services and supplies. Assist employers and agents with questions regarding healthcare resources and procedures for their employees and clients. Practice and model effective communication skills: both written and verbal. Utilize and promote use of evidence-based tools. Utilize lean methodologies for continuous improvement. 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. Perform other duties as assigned. SUCCESS PROFILE Work Experience: Minimum of three (3) years of clinical experience, including case management. Insurance industry experience preferred. Education, Certificates, Licenses: Clinical Social Worker, Licensed Professional Counselor, or Licensed Independent Clinical Social Worker with unrestricted license required in current state of residence. OR Registered Nurse with current appropriate unrestricted state license based on line of business: Commercial and Medicare: Oregon, Idaho or Montana, and Washington; Medicaid and DSNP: Oregon. Certified Case Manager Certification (CCM) as accredited by CCMC (The Commission for Case Management) strongly desired at time of hire. CCM certification required within two years of hire. Knowledge: Knowledge of health insurance and state mandated benefits. Experience and expertise in case management practice including advocacy, assessment, planning, communication, education, resource management and service facilitation. Ability to deal effectively with people who have various health issues and concerns. Knowledge and understanding of contractual benefits and options available outside contractual benefits. Knowledge of community services, providers, vendors and facilities available to assist members. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. Ability to work independently with minimal supervision. 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 5% of the time. Skills: Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork Compensation Disclaimer The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range. Base Range: $70,950.00 - $106,424.99Our 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.

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, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource 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 role of an Appeals Clinician is to accurately and succinctly represent the clinical component of an appeal. This is accomplished by close collaboration with external and internal partners/departments, assuring regulatory compliance, and eloquently representing the member/provider interests. Duties include but are not limited to: presenting the clinical component of appeals through thorough case review, careful research, application of policies, best practice standards, and available current, peer-reviewed information. The Appeals Clinician provides a concise summary of the appeal and represents the interests of the appealing party to the medical director for final determination. Essential Responsibilities: Represent PacificSource Health Plans with external customers and maintain positive working relationships. Review appeal requests for appropriateness of care within established evidence-based criteria sets. Work with Medical Directors to facilitate appeals within established timeframes and regulatory guidelines. Prepare case presentations for educational purposes and collaborative efforts with each LOB. Interact with other PacificSource personnel to assure quality customer service is provided. Act as an internal resource by answering questions requiring medical or appeal interpretation that are referred from other departments. Utilize Lean methodologies for continuous improvement. Utilize frequent 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. Collaborate with the leadership team, as well as other departments, for maintenance and accuracy of system resources Collect and interpret accurate claims data as needed for complete appeal review Ability to research and interpret various tools such as; OHA guidelines, member handbooks, provider contracts, NCCI standards, etc. Supporting Responsibilities: Serve on designated committees, teams, and task groups, as directed. Represent the Appeals and Grievance Department, both internally and externally, as requested by Medical Director, the Appeals and Grievance Manager, and The Director of Health Services Quality Assurance and Appeals and Grievances. 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. Perform other duties as assigned. SUCCESS PROFILE Work Experience: Minimum of three (3) years of nursing or behavioral health experience with varied medical and/or behavioral health exposure and capability required. Experience in acute care, case management, including cases that require rehabilitation, home health, behavioral health, and hospice treatment strongly preferred. Insurance industry experience helpful, but not required. Education, Certificates, Licenses: Registered Nurse or licensed behavior health specialist with current unrestricted state license. Within six (6) months of hire, licensure may need to include Oregon, Montana, Idaho, Washington and/or other states as needed. Knowledge: Thorough knowledge and understanding of medical and behavioral health processes, diagnoses, care modalities, procedure codes including ICD and CPT Codes, health insurance and state-mandated benefits. Understanding of contractual benefits and options available outside contractual benefits. Ability to use computerized systems for data recording and retrieval. Assures patient confidentiality, privacy, and health records security. Establishes and maintains relationships with community services and providers. Maintains current clinical knowledge base and certification. 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 5% of the time. Skills: Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork Compensation Disclaimer The wage range provided reflects the full range for this position. The maximum amount listed represents the highest possible salary for the role and should not be interpreted as a typical starting wage. Actual compensation will be determined based on factors such as qualifications, experience, education, and internal equity. Please note that the stated range is for informational purposes only and does not constitute a guarantee of any specific salary within that range. Base Range: $70,950.00 - $106,424.99Our 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.