Clinical Service Representative I

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Job ID: View phone number on us.fitly.work Status: Full-Time Regular/Temporary: Regular Shift: Day Job Facility: UPMC Health Plan Department: UM CM Operations Location: 600 Grant St, Pittsburgh, PA Union Position: No Salary Range: $ 17.78-27.95 USD

UPMC Health Plan's Clinical Operations team is seeking a Clinical Service Representative I! This role is eligible for work-from-home opportunities based on performance and to management's discretion. Hours for this role will vary with shifts scheduled between 8 AM - 8 PM, Monday through Friday.

The Clinical Service Representative (level 1) acts as an advocate for Health Plan customers (members, providers, facilities etc.) by providing guidance, interpretation and education on benefit coverage levels, Health management/Case management programs and various program inquiries. Responsible for efficient and courteous resolution of verbal and written inquiries to ensure customer satisfaction while maintaining call service and quality standards. The Clinical Service Representative (level 1) will also provide non-clinical support for the Medical Management activities by serving as the first line of contact for utilization management activities.

Responsibilities:

• Answer incoming inquiries from UPMC Health Plan members and providers
• Perform callbacks to members/providers to supply authorization decisions
• Conduct and document outbound calls to clarify, follow up and resolve customer inquiries
• Assist with scheduling members medical appointments to ensure that the Health Plan customers receive routing or follow-up care as indicated
• 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
• Facilitate transportation needs
• Complete initial review of all faxed material
• Manage and triage calls and electronic cases that may or may not require clinical intervention
• Create cases in the authorization system when appropriate
• Maintain or exceed designated quality and production standards
• Remain current on all department policies, procedures, plan benefit designs and modification
• Provide assistance to other departments during periods of backlog
• Maintain strict confidentiality related to medical records
• Must adhere to all HIPPA regulations

Qualifications:

• High School Graduate
• 1 year of customer service or call center experience required
• 1 year clerical, data entry or office experience preferred
• Ability to make independent decisions
• Medical Terminology or experience in health care environment preferred
• 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

  Licensure, Certifications, and Clearances:

• Act 34

UPMC is an Equal Opportunity Employer/Disability/Veteran

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