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UM CLINICAL SUPPORT SPECIALIST - HOAG CLINIC UTILIZATION MGMT

Department:  Business Services
Status:  Full Time
Shift:  1st

The UM Clinical Support Staff member will assist the UM Nurse and the UM team with any non-clinical tasks such as answering the phone, faxing information, printing the letters, notifying the patient and the provider as appropriate, checking eligibility, verifying discharge dates and admission.  Position requires the ability to assist with the collection of medical records, clarifying benefits and eligibility, reaching out to the provider for any clarification with the guidance from the UM Nurses and/or UM Medical Director, verifying a request for information, compliance with HIPAA and privacy standards, and accurately enters information into the Referral Management systems.

 

Essential Job Functions: 

  • Conducts eligibility and benefit verifications via the plan’s website or outbound calls to the plan’s customer service department and document the verified information into the medical management system.
  • Verify benefits and coordination of benefits information which includes but not limited to Other Insurance information, Subrogation, Potential Third-Party Liability, Benefit Exclusion and Limitations.
  • Verify members address and contact information listed on the provider’s office records/ EMR for incoming UM referrals/authorizations and coordinate with the eligibility for any member information changes.
  • Assist the UM Nurse as indicated with any prior-authorization needs such as Home Care, DME, request for drug prior authorization, outpatient procedure and surgery, experimental and investigational, clinical trials or potential cosmetic.
  • Accurately enter information into the Referral Management system and ensures timely processing of the authorization request in compliance with Federal, State, Health Plan and Certification requirements.
  • Will answer all in-coming and out-going phone calls that is related to the following activities: 1. Intake of incoming patient referrals and authorization requests, 2. Gathering, verifying and requesting any pertinent information, 3. Warm transfer the caller to the appropriate department as necessary, 4. Verifying admissions and discharge information, 5. Any other phone coverage and coordination needs.
  • Assists the Clinical staff in gathering any pertinent medical information such as history and physical medical information, diagnostic testing, any conservative measures, and other information needed for case reviews.
  • Ensure any faxes received are scanned and attached to the correct review/s and notify the UM Nurse that additional information was received.
  • Complete any assigned tasks that include distributing review requests, processing letters or authorizations, member or provider notification as appropriate, sorting faxes received, and other tasks as appropriate.
  • Make follow up calls to patients as delegated by the UM Nurse per department policies and procedures.
  • Administratively approve requests based on the Auto Approval Rule Guidelines.
  • Follow all department policies and procedures.
  • Other duties as assigned

 

 

Education, Training and Experience

           

Required:

  • Must be a High School Graduate/GED or Equivalent
  • Worked in the Healthcare Field such as Hospital, Insurance, Medical Group or Risk Bearing Organization
  • Demonstrate competency in Medical terminology, ICD – 10 Codes, CPT Codes, and HCPC Codes, Copay, Deductible Co-insurance

 

Preferred:

  • Worked as Non-Clinical Staff member with the Prior – Authorization Team, Case Management Team or Medical Office Facility

 

Skills or Other Qualifications

 

Required:

  • Must be organized in prioritizing workloads and case assignments
  • Must have excellent typing and computer skills.
  • Demonstrate strong communication and customer service skills.
  • Experience in using MS Office platforms such as MS Outlook, MS Excel, MS Word
  • Experience in working using an EMR or a Medical Management System

 

License and Certifications

Required: N/A

Preferred: Medical Assistant (MA)


Nearest Major Market: Orange County
Nearest Secondary Market: Los Angeles

Job Segment: Clinic, Medical, Manager, Home Care, Medical Assistant, Healthcare, Management

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