Clinical Services Representative II

Job Description

This position supports PEHP's efforts to mitigate the rising cost of health care and provide excellent customer service. This position performs a variety of support duties including clinical services technical support, customer service support, and education through inbound and outbound communications. This position also collaborates with PEHP nurses, pharmacists, and doctors; provides customer service to PEHP members and network physicians; solves problems with pre-authorizations or claims and assists the Clinical Management department in pre-authorization evaluation and the disputed/appealed pre-authorization process. The successful candidate will have excellent communication skills, a basic understanding of medical terminology, understand medical claims payments, the ability to learn and apply new information, and is willing to go the extra mile to provide excellent customer service. The incumbent must always demonstrate good judgment, high integrity, and personal values consistent with the values of URS.

ESSENTIAL JOB FUNCTIONS AND DUTIES

• Acts as a member advocate to resolve member/provider insurance problems, which may be related to requests for pre-authorization of benefits, claims, and/or benefit interpretation.
• Responds to issues, questions, and concerns from PEHP members, providers, and internal customers via incoming and outgoing phone calls, written correspondence, fax, email, etc. Responds to questions regarding policy description and interpretations, payment processes, and eligibility for covered services. Assists callers in the proper procedures related to claims corrections and appeals.
• Receives and responds to incoming phone calls from policy holders, claimants, providers, pharmacies, and representatives of other insurance companies. Responds to complex questions regarding medical and pharmacy claims processing, policy descriptions and interpretations, payment processes, coordination of benefits, and eligibility of covered services.
• Educates members, providers, and pharmacies through outbound phone calls on company policies and plan benefits.
• Acts as first level review for cases being entered into the case management system.
• Assists in providing reporting regarding high dollar cases, reinsurance requirements, cost savings, outreach calls, and disease management program tracking.
• Assists in member outreach calls for disease management programs.
• Provides information on co-pay assistance programs offered through pharmaceutical manufacturers.
• Identifies requests for out-of-network services and directs care to in-network providers. Educates on out-of-network costs and potential for balance billing.
• Evaluates and determines coverage on prior authorization requests for pharmacy, medical benefits, and durable medical equipment (DME) in a timely manner.
• Prepares and collects clinical information for disputes and appeals. Forwards to the appropriate Clinical Management staff.
• Works closely with providers, vendors, and members to obtain all necessary information for pre-authorization and ensures completion in a timely manner.
• Resolves clinical issues pertaining to pre-authorizations, disputes, eligibility, mail order, benefits interpretation, and claims payments.
• Communicates pre-authorization and disputed prior authorization approvals/denials with physicians, members, PEHP Member and Provider Services department, PEHP Clinical Management department, and the PEHP Member Claims department through mailings, inbound/outbound phone calls, and the PEHP Message Center.
• Maintains and reconciles Medicare D electronic eligibility files.
• Assists in Clinical Management department mailings.
• Manages a high volume of incoming calls.
• Maintains regular and reliable attendance.
• Maintains strict confidentiality (HIPAA compliant).
• Performs other related duties as assigned.

Required Experience

Education and Experience

High School diploma and three (3) years of progressively responsible experience in a medical setting (insurance, practice, facility, etc.), or an equivalent combination of education and experience.

Certification as a Nursing Assistant (CNA), Medical Assistant (AAMA), Current Procedural Terminology (CPT), registered pharmacy technician (CPhT), or other health care related license/certificate is preferred.

Certified Professional Coder (CPC) or medical terminology certification and or specific experience in claims processing, computer software applications, and electronic billing procedures is preferred.

Knowledge, Skills, and Abilities

This list contains knowledge, skills, and abilities that are typically associated with the job. It is not all-inclusive and may vary from position to position:

Required technical skills include the working knowledge and ability of:

• Various office management systems related to alpha and numeric record keeping.
• Healthcare Information Systems.
• Pharmacy software programs.
• Electronic billing procedures.
• Personal computer operations.
• Microsoft Office Suite.
• 10-key.

Required working knowledge of:

• Medical, dental, pharmaceutical and Medicare Supplement claims adjudication policies, procedures, and processes.
• Intricacies related to medical, dental, pharmaceutical, and mental health claims.
• Claims review processes and procedures.
• Healthcare coding.
• Enrollment processes.
• Basic medical terminology.
• Pharmacy adjudication policies.
• Intricacies related to drug usage, dosage, definitions, and codes.

Must possess excellent communication skills:

• Telephone etiquette.
• Public relations skills.
• Communicate effectively verbally and in writing.
• Establish and maintain effective working relationships with professionals, executives, department heads, coworkers, and the public.
• Analyze a variety of escalated issues and problems and make recommendations directly related to pharmacy claim functions.

Must have the ability to:

• Multi-task by handling a variety of duties in a timely and efficient manner.
• Draft technical reports, documents, manuals, and instructions.
• Document information accurately and succinctly.
• Apply intermediate mathematics related to the metric system to calculate drug dosages as related to pharmacy/medical claims.
• Maintain effective working relationships with professionals, department heads, co-workers, and the public.
• Follow written and verbal instructions.
• Follow a well-organized work routine.
• Work well in a team environment as well as independently.
• Deal effectively with stress caused by workload and time deadlines and handling difficult or irate phone calls.
• Prioritize work.
• Perform within deadlines.
• Follow through with assignments.

The incumbent must always demonstrate judgment, high integrity, and personal values consistent with the values of URS.

Work Environment

Incumbent performs in a typical office setting with appropriate climate controls. Tasks require a variety of physical activities which do not generally involve muscular strain, but do require activities related to walking, standing, stooping, sitting, reaching, talking, hearing, and seeing. Common eye, hand, finger dexterity required to perform essential functions.