Job Title: Clinical Support Representative
Why work at OpTech?
OpTech is a woman-owned company that values your ideas, encourages your growth, and always has your back. When you work at OpTech, not only do you get health and dental benefits on the first day of employment, but you also have training opportunities, flexible/remote work options, growth opportunities, 401K and competitive pay. Apply today! To view our complete list of openings, please visit our website at www.optechus.com.
RESPONSIBILITIES:
Engagement Description:
- The Clinical Support Representative’s primary responsibility is to facilitate and coordinate preadmission/admission reviews, prior approvals and referral requests through the medical review cycle in compliance with Rule 10, DOL (department of labor), NCQA (National Committee for Quality Assurance), and URAC (Utilization Review Accreditation Commission) timeliness requirements.
- This includes generating and performing quality assurance of correspondence, entering authorizations to ensure appropriate claims processing, and maintaining electronic medical records.
- The Clinical Support Representative is also responsible for answering department phone calls and evaluating issues and questions from internal and external customers.
- The Representative provides exceptional customer service when interacting with all internal and external customers and always maintains the highest level of confidentiality.
Primary Responsibilities:
- Evaluate incoming requests and determine proper distribution throughout the department and company
- Analyze and research requests to determine Our Client’s member/benefit eligibility, including identifying OPL, waiting periods, benefit maximums, etc.
- Coordinate requests and create cases for prior approval and pre-certification in multiple systems (including: Customer Focus, Acuity, MHS, AS400) for review by clinical reviewers
- Identify and refer members for case management based on diagnoses and types of service being requested
- Enter and update authorizations to ensure appropriate claims processing based on clinical reviewers’ decision
- Correspond with members and providers regarding decisions about requested services and to obtain medical records when necessary
- Participate in on-going efforts to comply with NCQA, Rule 10 and URAC standards by performing quality assurance of outgoing correspondence, understanding time variations of requirements and responding to requests within the timeliness guidelines
- Work collaboratively with other departments to obtain additional information to resolve claims, inquiry, and prior approval/pre-certification requests
- Professionally and courteously answer, manage and appropriately route department telephone calls, processing calls regarding pre-certification and prior approval of services and referring to other departments when necessary
- Review and respond to issues and questions from internal and external customers, both verbally and in writing
- Act as a liaison between the Plan’s members, outside vendors and providers, and Our Client
- Acquire and implement a high level of professional and service excellence when interacting with all customers, external as well as internal
- Develop cooperative relationships both within and outside of the company
- Provide clear, concise, and accurate interpretation of Plan certificate language, benefit administration, and all information communicated to customers
- Manage electronic medical records and all incoming PHI, always maintaining the highest level of confidentiality
- Assist clinical staff in gathering data, researching claims/authorizations, obtaining medical records, and other duties as needed
COMPETENCIES: (KNOWLEDGE, SKILLS, AND ABILITIES):
Subject Matter Expertise:
- Understanding of all of Our Clients’ benefits and products
- Understanding of the claims adjudication and data systems
- Understanding of medical terminology and medical coding, to include ICD-9, HCPCS, and CPT4
- Understanding of URAC, NCQA, Rule 10, DOL, and other regulatory standards pertaining to Case/Care Management
Computer Skills (or other Technical skills):
- Competent in use of MS Office Applications (specifically Outlook, Word and Excel), AS400 legacy, MHS, Lotus Notes, Customer Focus, OnBase, The Knowledge Center, FEP Direct, web browsing, Acuity and phone system
Communication Skills:
- Strong written and oral communications skills, with advanced listening skills to be able to identify provider and subscriber concerns
Interpersonal Skills:
- Strong interpersonal skills, including the ability to effectively maintain a consistently pleasant, courteous, and positive manner in responding to all subscriber and provider telephone inquiries, including those from angry or difficult customers
Organizational Abilities:
- Strong organizational skills, including the ability to work independently, demonstrate attention to detail with accuracy, utilize resources, and manage/prioritize increasing volume within quality standards
Analytical Skills:
- Strong analytical skills, including research and analysis
QUALIFICATIONS:
Top 3 Required Skills/Experience:
- Subject Matter Expertise:
- Understanding of plan benefits and products
- Understanding of claims adjudication and data systems
- Understanding of medical terminology and medical coding, to include ICD-9, HCPCS, and CPT4
- Understanding of URAC, NCQA, Rule 10, DOL, and other regulatory standards pertaining to Case/Care Management
- Computer Skills:
- Competent in use of MS Office Applications (specifically Outlook, Word and Excel)
- AS400 legacy, MHS, Lotus Notes, Customer Focus, OnBase, The Knowledge Center, FEP Direct
- Web browsing
- Acuity and phone system
- Communication Skills:
- Strong written and oral communications skills, with advanced listening skills to be able to identify provider and subscriber concerns
Required Skills/Experience:
- 1-3 years of experience in the healthcare industry, preferably health insurance
- Interpersonal Skills: Strong interpersonal skills, including the ability to effectively maintain a consistently pleasant, courteous, and positive manner in responding to all subscriber and provider telephone inquiries, including those from angry or difficult customers
- Organizational Abilities: Strong organizational skills, including the ability to work independently, demonstrate attention to detail with accuracy, utilize resources, and manage/prioritize increasing volume within quality standards
- Analytical Skills: Strong analytical skills, including research and analysis
Preferred Skills/Experience – Optional but preferred skills/experience. Include:
- Experience in health insurance claims processing
Education/Certifications:
- High School Diploma and 1-3 years of experience in the healthcare industry, preferably health insurance, is required.
- Associates Degree and experience in health insurance claims processing is preferred.
Discretion and Judgment:
- Follows established guidelines, procedures, or techniques to perform the job, and is expected to seek approval to deviate substantially from or to change defined procedures
Nature of Duties:
- Primary duties are manual in nature (i.e. data entry, mail sorting, shipping)
Focus of Work:
- Primary duties are directly related to general business operations
Knowledge Requirements:
- Ability to perform the job duties requires a general orientation, work unit instructions, an understanding of procedures and policies, on-the-job training, and/or mentoring
Physical Demands – Amount of Time:
- Standing – Up to 1/3
- Walking – Up to1/3
- Sitting – Over 2/3
- Talking and Hearing – Over 2/3
- Pushing/Pulling – Up to1/3
- Reaching with hands and arms – Up to 1/3
- Fine Dexterity – 1/3 to 2/3
- Repetitive use of hands – Over 2/3
- Aural Acuity – Over 2/3
OpTech is an equal opportunity employer and is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, pregnancy, status as a parent, disability, age, veteran status, or other characteristics as defined by federal, state or local laws. https://www.optechus.com/eeo_self_identification/
