Job Details

Position 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, and completion of member/provider communications

Responsibilities and Qualifications

Duties and Responsibilities:

• Assists with medical record documentation requests and leverages medical management system to initiate case and/or authorization to support clinical processes (e.g. UM, CM).
• Conducts 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).
• Supports administrative functions with community events (e.g. health fairs)
• Accurately documents all interventions in the member's medical management record in accordance with established policies and procedures.
• Actively participates in supporting department compliance and performance through administrative activities such as report monitoring/distribution, and other tasks as assigned by leadership.
• Adheres to all regulatory and compliance standards, including adherence to all Capital and department specific policies and procedures.
• Interacts courteously and professionally with customers, including internal staff, vendor partners, providers, and members to support collaborative medical management functions.
• Identifies and reports potential quality of service/care issues as established and within the guidelines of intradepartmental processes.
• Promotes personal growth through participation in staff meetings, appropriate in-services, and corporate training.
• Identifies opportunities and proposes alternatives for improving the Population Management functions.

• 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.

• 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.

• High School Diploma required.
• Continued higher education preferred.