Clinical Support Specialist - Member Outpatient Services

Job Description

POSITION SUMMARY:

To be fully engaged in providing No Harm / Quality, Customer Experience, and Stewardship by: enabling and supporting responsibilities associated with Utilization Management and Case Management, to include all non-clinical functions, to optimize customer satisfaction and positively impact productivity. Success in this position will be based on the individual's ability to effectively prioritize and manage work in an accountable and responsible manner and consistently meet departmental standards for production and quality.

PRIMARY ACCOUNTABILITIES:

• Maintains confidentiality and adheres to HIPAA requirements.
• Maintains a clean/safe work environment.
• Properly identifies and elevates clinical issues to the appropriate associate level.
• Coordinates Utilization Management and Case Management intake activities by following documented business policies, procedures, and workflow completely, accurately and within the required time frames.
• UM and CM data is entered into systems with accuracy and completeness.
• Demonstrates knowledge of accreditation and regulatory Utilization Management and Case Management requirements.
• Achieves individual productivity metrics set by management.
• Contributes towards departmental performance
• Provides accurate and professional service to Customers.
• Demonstrates sensitivity and shows pro-active behavior in addressing customer needs.
• Interacts with Health First Health Plan interdepartmental associates to resolve issues both timely and efficiently.
• Responds to Customer inquiries related to: Authorization requests, decisions and extensions; Benefit coverage and exclusions; Eligibility; Plan Providers; Claims payments and non payments.
• Customer Centric approach to daily activities and outcomes.

Qualifications:

QUALIFICATIONS REQUIRED:

• High school diploma or GED required
• Associate Degree or higher education degree preferred
• 2+ years of call center or administrative experience in Healthcare or in the Health Insurance industry preferred
• Minimum 1+ year in clinical or health care insurance administrative setting, call center setting or other customer supporting role
• Ability to accurately type 45 wpm while speaking with provider/member/vendor or other via telephone
• 1+ year Knowledge of clinical coding preferred
• 1+ year Knowledge of HIPAA compliance requirements preferred
• 1+ year Medical and Hospital Claims Knowledge preferred
• Strong data entry skills required
• Strong attention to detail and quality of work product
• Strong knowledge of medical terminology and familiarity with medical scenarios required
• Advanced Computer Skills e.g. navigation and workflow within an EMR, Benefit Administrative system(s) or medical management applications and Microsoft Office Applications required