[Hiring] Clinical Support Specialist @Capital Blue Cross

Role Description

Provides administrative support to assigned clinical team, as directed by the Team Lead and/or Manager. The Clinical Support Specialist will perform administrative tasks that support clinical processes (e.g. UM, CM, PHM), including but not limited to:

• Building medical management records (e.g. authorizations and referral management)
• Compliance report monitoring
• Completion of member/provider communications

Responsibilities include:

• Assisting with medical record documentation requests and leveraging medical management system to initiate case and/or authorization to support clinical processes (e.g. UM, CM)
• Conducting fax and telephonic outreach; and written communications to members and/or providers to communicate status of UM/CM processes (e.g. verbal notification, engagement status, discharge plan)
• Supporting administrative functions with community events (e.g. health fairs)
• Accurately documenting all interventions in the member’s medical management record in accordance with established policies and procedures
• Actively participating in supporting department compliance and performance through administrative activities such as report monitoring/distribution, and other tasks as assigned by leadership
• Adhering to all regulatory and compliance standards, including adherence to all Capital and department specific policies and procedures
• Interacting courteously and professionally with customers, including internal staff, vendor partners, providers, and members to support collaborative medical management functions
• Identifying and reporting potential quality of service/care issues as established and within the guidelines of intradepartmental processes
• Promoting personal growth through participation in staff meetings, appropriate in-services, and corporate training
• Identifying opportunities and proposing alternatives for improving the Population Management functions

Qualifications

• Strong organizational and time management skills
• Demonstrated strong attention to detail and accuracy
• Ability to follow job responsibilities as outlined in departmental policies and procedures
• Excellent written and oral communication skills

Requirements

• Working knowledge and operation of a personal computer, including proficiency in Microsoft Office applications
• Working knowledge of medical terminology
• Working knowledge of the health insurance industry, health plan benefits and product lines (e.g., PPO, POS, HMO, FEP, Senior Products, Traditional/Comprehensive)
• Knowledge of regulatory and accreditation standards and requirements (e.g. NCQA, CMS)
• Minimum 2 years’ experience in the medical field (e.g. medical assistant, medical secretary) or 2 years’ experience in a managed care clinical department

Education and Certifications

• High School Diploma required
• Continued higher education preferred

Benefits

• Comprehensive benefits package including Medical, Dental & Vision coverage
• Retirement Plan
• Generous time off including Paid Time Off, Holidays, and Volunteer time off
• Incentive Plan
• Tuition Reimbursement