Job Details

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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 UM Referrals/Intake Auditor is responsible for reviewing and evaluating the accuracy, timeliness, and compliance of referral and intake processes within the Utilization Management department. This role ensures that referral requests, authorization determinations, and intake workflows meet regulatory guidelines, payer requirements, and internal policies, thereby supporting the organization's goals of quality care, cost containment, and member satisfaction. This role will also collaborate with Training Coordinators, Regulatory Reporting, and Leadership to identify individual and team training opportunities for all Utilization Management (UM) staff.

Essential Responsibilities:

• Conduct regular audits of referral and intake files (e.g., documentation, coding, and authorization requests) to ensure they meet organizational and regulatory standards across Medicare, Medicaid, and Commercial lines of business.
• Verify accuracy of referral documentation, including member eligibility, benefit coverage, and clinical criteria used in decision-making.
• Identify compliance gaps, potential errors, or inefficiencies in the referral and intake process and make recommendations for corrective actions.
• Develop and maintain audit tools and checklists to measure adherence to policies and standard operating procedures (SOPs) in referrals and intake.
• Track and trend audit results (e.g., error rates, turnaround-time compliance) to identify patterns or areas of improvement.
• Collaborate with team members to update SOPs as needed, ensuring alignment with best practices and industry guidelines.
• Generate audit reports and present findings to UM leadership, highlighting key metrics (accuracy, compliance rates, TAT).
• Provide data-driven insights to improve referral processes, authorization workflows, and member experience.
• Develop corrective action plans (CAPs) in partnership with stakeholders to address audit findings and monitor progress through re-audits.
• Assist in the training of Referrals/Intake staff, sharing audit insights and process updates to drive compliance and performance improvements.
• Collaborate with UM Trainers to develop or refine educational materials, job aids, and refresher sessions that address common errors or knowledge gaps.
• Provide coaching or individual feedback to staff identified through the audit process for improvement opportunities.
• Stay current on federal, state, and payer-specific guidelines (e.g., CMS regulations, NCQA,) that affect UM referral and intake practices.
• Ensure that changes in laws, regulations, or payer contracts are promptly integrated into audit criteria and departmental procedures.

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: A minimum of four (4) years of experience in Utilization Management, referrals/intake, or healthcare auditing. Prior audit or quality assurance background is strongly preferred.

Education, Certificates, Licenses: High school diploma or equivalent required. Bachelor's or Associate's degree, medical assistant certification, licensed professional nurse, or certified professional coding certification preferred.

Knowledge: Thorough knowledge and understanding of the utilization management life cycle, including intersection with Care Management, Special Functions, Claims, and Appeals and Grievances. Knowledge of health plan eligibility, benefits, medical interventions, and management. Ability to work independently with minimal supervision, prioritize responsibilities, and manage challenging situations with diplomacy. Must function as a leader in a collaborative, cohesive community. Excellent oral and written communication skills including the ability to provide constructive feedback and setting work standards. Medical terminology, computer competency, Microsoft Outlook, Word and Excel experience required. CPT/ICD coding, call tracking software, and electronic health record experience required.

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 10% of the time.

Skills:

Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions.Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

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