Clinical Support Specialist

3 weeks ago

Taguig, Philippines Eviden Full time

Shift Schedule: Nightshift

Work Setup: Hybrid

Summary:

  • The clinical support specialist (CSS) provides administrative support to clinical staff within Member Health. The CSS adheres to established customer service standards of accuracy, courtesy, and professionalism. This position supports timely determination turnaround times on all prior authorization requests and inpatient notifications received via telephone, fax, or mail. This position is responsible for logging and routing requests for authorization to the appropriate clinical reviewer. This position must maintain a working knowledge and understanding of CDPHP benefit plans, contracts, provider networks, and Resource Coordination policies to maximize effectiveness.

Qualifications and Experience:

  • Must be a graduate of bachelor's degree.
  • A minimum of two (2) years' experience in a health insurance related discipline required.
  • Utilization management experience is preferred.
  • Knowledge of managed care, health plan benefits, and be able to carefully assess medical information.

Duties and Responsibilities:

  • Review scanned documents in assigned inpatient and outpatient queues.
  • Research requests for authorization, verifying eligibility/benefits, reviewing authorization history, necessary to completing review.
  • Outreach physician offices and facilities to obtain missing information.
  • Initiate authorization and route to clinical reviewer.
  • Obtain demographic information for providers and submit request for provider load to core system.
  • Prepare cases for submission to external reviewer.
  • Generate letters from core systems for Utilization Review, Behavioral Health, Ambulatory Review and Coding:
  1. Extensions
  2. Approvals
  3. Denials
  4. Member/Provider Policy Requests
  5. External Reviews
  • Provide verbal and written notification to members and providers of approved determination of requested service(s).
  • Document all contacts related to member or provider inquiries in the core system according to departmental and corporate standards.
  • Achieve and maintain production and quality performance standards as set by the department.
  • Assist with peer training during the initial phase of the orientation process.
  • Assist with cross coverage for other administrative staff within the department.
  • The employee agrees to comply with CDPHP's Corporate Compliance Policy and all laws, rules, regulations and standards of conduct relating to the Corporate Compliance Policy and has a duty and obligation to report any suspected violations of any law, the standards of conduct or Corporate Compliance Policy to his or her immediate Supervisor, the fraud and abuse hotline, the Compliance Officer, the Compliance Director, Human Capital Management or the Chief Executive Officer.
  • Perform other duties as assigned.

Skills & Abilities:

  • Perform work in a fast-paced environment with frequent changes.
  • Ability to multitask and work in multiple systems.
  • Ability to review documents and use critical thinking.
  • This position deals with reviewing medical information and creating Authorizations which include Diagnosis Codes, CPT codes, medical terminology related to different types of Inpatient and Outpatient services.
  • Strong data entry skillset required.
  • Demonstrated customer service skills, and possess excellent listening, communication, and interpersonal skills.
  • Demonstrated ability to illicit required information; interact professionally with difficult callers, provider practitioners and members with ongoing assistance and education regarding plan requirements.
  • Ability to apply established criteria against documentation to identify and resolve issues is required.
  • PC experience in a Windows environment is required.
  • The ability to manage multiple tasks simultaneously and in an organized manner is required.

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