Your Role

The MCS Clinical Service Intake team responsible for timely and accurate processing of Treatment Authorization Requests. The Clinical Services Coordinator (CSC), Intermediate will report to the Supervisor of Clinical Services Intake . In this role you will be for supporting clinical staff day to day operations for Promise (Medi-Cal) or Commercial/Medicare lines of business

Your Work

In this role, you will:

• Work in a production-based environment with defined production and quality metrics.
• Process Faxed /Web Portal /Phoned in Prior Authorization or Hospital Admission Notification Requests, Utilization Management (UM)/Case Management (CM) requests and/or calls left on voicemail.
• Select support for Case Manager such as mailings, surveys.
• Data entry including authorization forms, high risk member information, verbal HIPPA authorizations information for case creation.
• Support to Advanced/Specialist CSC.
• Assign initial Extension Of Authority (EOA) days, or triage to nurses, based on established workflow.
• Research member eligibility/benefits and provider networks.
• Serves as initial point of contact for providers and members in the medical management process by telephone or correspondence.
• Assists with system letters, requests for information and data entry.
• Provides administrative/clerical support to medical management.
• Intake (received via fax, phone, or portal). Data entry including authorization forms, high risk member information, verbal HIPPA authorizations information for case creation.
• Provide workflow guidance to offshore representative.
• Other duties as assigned.

Your Knowledge and Experience

• Requires a high school diploma or equivalent
• Requires at least 3 years of prior relevant experience
• May require vocational or technical education in addition to prior work experience
• 1-year work experience within the Medical Care Solutions' Utilization Management Department or a similar medical management department at a different payor, facility, or provider/group.
• In-depth working knowledge of the prior authorization and/or concurrent review non-clinical business rules and guidelines, preferably within the Outpatient, Inpatient, DME and/or Home Health, Long Term Care and CBAS areas
• In-depth working knowledge of the systems/tools utilized for UM authorization functions such as AuthAccel, Facets, PA Matrix or other systems at a different payor, facility, or provider/group.
• Ability to provide both written and verbal detailed prior authorization workflow instructions to offshore staff.
• Ability to work in a high-paced production environment with occasional overtime needed (including weekends) to ensure regulatory turnaround standards are met.
• Knowledge of UM regulatory Turn Around Time (TAT) standards
• Knowledge of clinical workflow to assist nurses with case creation, research/issue resolution and other UM related functions, as necessary.

Pay Range

The pay range for this role is: $ 20.47 to $ 28.66 for California.

Note

Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.

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