Job Description

Your Role

The Specialty Services team is a branch off the MCS Intake team. The Clinical Support Coordinator will report to the Specialty Services Manager. In this role you will be required to process phone and faxed requests for Continuity of Care, Access to Care for both commercial and Medi-Cal membership. This role may also require Peer or Peer provider support and other duties within Medical Care Solutions.

Your Work

In this role, you will:

• Process faxed/phoned in authorizations, UM/CM requests, special processing/case types and/or calls left on voicemail 
• Monitor specific queues/workstreams and generates pre-defined reports to identify and resolve common errors
• Handle customer/provider problematic calls
• Check member history for case management triage and research member eligibility/benefits and provider networks 
• Assign initial EOA days, or triage to nurses, based on established workflow 
• Assist with audit file prep 
• Collaborate with team members on difficult cases for best practices
• Promote and maintain and ensure a safe, secure, and healthy work environment by following standards and procedures and complying with company policy 
• Assist our Clinical staff with case questions, research, and special requests
• Cross train in other MCS process as needed
  
   

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.
• Preferred the ability to work independently using documented processes
• Preferred the ability to make decisions quickly, effectively, and without doubt

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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