Clinical Support Spec II

Position Description

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it's why our employees consistently vote us one of the "Best Places to Work in PA."

The Clinical Support Specialist I and II/Sr. Clinical Support Specialist is responsible for working within their assigned Medical Management unit to perform tasks assigned by the Clinical Team Lead. These tasks will be based on the unit's needs. The assigned activities include, but not limited to the following: utilizing computer systems to research pertinent information regarding eligibility and benefits of members, construction of case structure through entering pertinent information into the computer systems and providing telephone support for members and providers to assist in answering questions pertinent to the activity of the assigned Medical Management unit. Provides administrative support to the Medical Management department is inclusive of the Preauthorization, Medical Claims Review, Concurrent Review and appeals units.

Responsibilities and Qualifications

• Responsible for maintaining unit service level goals.

• Conducts intake services, including the coordination between the units within the Clinical Management Department.

• Processes referrals/requests/records received for services and forwards to the appropriate member of the team after researching and/or verifying member eligibility and benefit information.

• Provides telephone support to the unit for assigned queue.

• Provides eligibility and claims status support, both internally and externally, for non-clinical issues relating to specific cases.

• Performs administrative duties to support the core functions of the unit, as requested, such as taking meeting minutes, monitoring office equipment to assure operating order, mails and distributes various letters created by staff, scheduling meetings, purging files, and faxing.

• Acts as the Records Point of Contact for assigned Unit.

• Promotes personal growth through participation in staff meetings, appropriate in-services and corporate training.

• Complies with established departmental policies and desktop procedures.

• Conducts self in a professional manner with staff in other departments within Capital BlueCross as well as the provider community.

• Works as a respectful member of the team in a collaborative manner to complete duties and to solve problems.

• Demonstrates the ability to be detail oriented and accurate with assigned work.

• Identifies opportunities for improvement of overall functioning of the unit to develop more efficient processes and to move the business forward.

• Assists in the orientation of new employees.

• Provides special project assistance as needed.

• Completes any special assignments/reports in a complete and timely manner.

• Participates in the development of desktop procedures related to position.

Education and Certifications:

• Possesses a high school diploma or G.E. D. with 2 to 3 years' experience in the medical health field (e.g., medical assistant, medical secretary) or 2 to 3 years' experience in a managed care clinical department.

• Working knowledge of medical terminology.

• Able to demonstrate competence with and/or ability to learn various health plan computer systems (e.g., FACETS, Impact Pro, FEP, CAIC, CCA and Image).

• Working knowledge of the insurance industry, health plan benefits and product lines (e.g., PPO, POS, HMO, FEP, Senior Products, Traditional/Comprehensive).

• Excellent customer service skills in order to work with internal and external customers, and ability to communicate effectively both verbally and in writing.

• Strong organizational skills with the ability to be flexible and prioritize workload based on departmental needs.

• Must have quality standards and capability to produce and record information with attention to detail, accuracy and within time standards established by the Sr. Team Lead/Manager.

• Able to perform basic mathematical calculations (e.g. addition, subtraction, multiplication and division).

• Experienced utilizing a PC and various software packages (e.g., Microsoft Office Suite) with keyboarding skills equivalent to 40 words per minute.

• Knowledge of regulatory and accreditation standards and requirements preferred. (e.g., NCQA, URAC, Pennsylvania Department of Health and Department of Insurance, ERISA, Act 68).

• Preferred experience in a managed care organization with specific experience related to clinical management.

Physical Demands:

Sedentary work involving significant periods of sitting, talking, hearing, keying and performing repetitive motions. Work requires visual acuity to perform close inspection of written and computer-generated documents as well as a PC monitor. Working environment includes typical office conditions.

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you'll help us live our mission of improving the health and well-being of our members and the communities in which they live.