Note: The job is a remote job and is open to candidates in USA. UPMC Health Plan is hiring a Clinical Service Representative I for its UM CM Operations team. The role advocates for members, providers, and facilities by addressing benefit and health management inquiries, providing non-clinical utilization management support, and coordinating customer care activities.
Responsibilities
- Facilitate transportation needs
- Perform call backs to members/providers to supply authorization decisions
- Conduct and document outbound calls to clarify, follow-up and resolve customer inquiries
- Create cases in the authorization system when appropriate
- Must adhere to all HIPPA regulations
- Remain current on all department policies, procedures, plan benefit designs and modification
- Provide assistance to other departments during periods of backlog
- Complete initial review of all faxed material
- Manage and triage calls and electronic cases that may or may not require clinical intervention
- Maintain strict confidentiality related to medical records
- Assist with scheduling members medical appointments to ensure that the Health Plan customers receive routing or follow-up care as indicated
- Answer incoming inquiries from UPMC Health Plan members and providers
- Maintain or exceed designated quality and production standards
- Attend offsite/onsite benefit fairs-interact with members and schedule appointments
- Conduct outbound member and provider calls in accordance with department initiatives and regulatory requirements
- Initiate assessments on members by obtaining all necessary member demographics and any available clinical information
Skills
- Must be legally authorized to work in the United States, without requiring, now or in the future, sponsorship for employment visa status
- High School Graduate
- 1 year of customer service or call center experience required
- Ability to make independent decisions
- Basic analytical skills necessary to evaluate customer inquiries
- Computer proficiency in database, word processing and spread sheet management required
- Excellent organizational, communication and problem-solving skills required
- Schedule flexibility to meet business needs
- Detail oriented
- 1 year clerical, data entry or office experience preferred
- Medical Terminology or experience in health care environment preferred
- Act 34
Benefits
- This position will predominantly work remotely.
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