Clinical Services Coordinator, Advanced - Specialty Services

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 5 years of prior relevant experience
• Requires flexibility and insightfulness
• Requires the ability to work independently using documented processes
• Requires the ability to make decisions quickly, effectively, and without doubt
• Previous MCS Intake experience preferred but not required
• 3 years of work experience within the Medical Care Solutions Utilization Management Department or a similar medical management department at a different payor, facility, or provider/group preferred. Experience with Medicare and/or Medi-Cal is preferred.
• In-depth working knowledge of the prior authorization review and non-clinical business rules and guidelines, preferably within the Pre-service area.
• In-depth working knowledge of the systems/tools utilized in the UM authorization functions such as AuthAccel, Facets, AEVS and PA Matrix or other systems at a different payor, facility, or provider/group preferred.
• 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 TAT standards
• Knowledge of clinical workflow to assist nurses with case creation, research/issue resolution and other UM related functions, as necessary.