POSITION SUMMARY

Provide support of Provider Portal, Utilization Management, Case Management, and Pharmacy, to include all non-clinical functions, to optimize clinical quality, meet Service Level Agreements (SLA) and positively affect productivity. Identify opportunities or deficiencies contributing to gaps in patient care (i.e. assisting with transition of care, care coordination, disease management, or any member who may need additional assistance).

PRIMARY ACCOUNTABILITIES

1. Proficiently and accurately identifies and documents a provider's network status, member’s plan, eligibility, contract, and benefits.
2. Maintain confidentiality and adheres to HIPPA requirements.
3. Accurately coordinates Utilization Management, Case Management, and Pharmacy support activities with the highest of quality and compliance adherence.
4. Explains technical options for providers in authorization submissions, assisting in portal navigation, various vendor authorization requirements and troubleshoots gaps in the process and appropriately referring providers’ offices to technical support help desk, provider relations and/or escalating to other resources.
5. Responsible for assisting the interdisciplinary care team in the provision of care navigation activities, and working with selected patients as assigned by high risk status or multiple health care coordination needs.
6. Review and prepares requests requiring clinical review by a pharmacist or nurse, which includes interpretation of all submitted medical records, lab results, office notes and provider supporting statements and assisting provider’s offices in completing requests.
7. Mentor, train and help develop new team members.
8. Actively identifies opportunities for lean process improvements. Accept and support change activities related to intake and referral processes participating in workgroups for claims, configuration and projects.
9. Monitor and accountable for Service Level Agreements, responding to inbound calls, e-mails, and queue’s.
   10. Liaison between other Health First Entities to educate on the Authorization process, Case Management referrals, systems used to make requests, vendors, websites utilized, process to registers and online resources available for self-service.
   11. Knowledgeable, savvy and adept with assisting providers with processes for submission of information, accessing information via the various portals and electronic health records assisting them with pulling from one system to submit to another when needed.
   12. High quality accuracy in data entry and creation of authorizations, cases and documentation.

MINIMUM QUALIFICATIONS

• Education: High school diploma or GED.
• Work Experience: One year experience in a call center environment or within the Healthcare/Insurance industry.
• Knowledge/Skills/Abilities: o Intermediate understanding of medical benefits, prescription drug coverage, and medical terminology. o Strong attention to detail, quality of work, and critical thinking skills. o Intermediate computer skills e.g. navigation and workflow within an EMR, benefit administrative system(s) or medical management applications, Microsoft Office Applications and the ability to accurately type 45 wpm while speaking on the phone.

PREFERRED QUALIFICATIONS

• Education: Associate’s degree or higher.
• Certification: Lean Yellow Belt certification.
• Knowledge/Skills/Abilities: Knowledge of HIPAA compliance requirements, compliance adherence and claims.

PHYSICAL REQUIREMENTS Sedentary – Office Workers

• Sedentary work involves sitting most of the time.
• Walking and standing or lifting more than 10 pounds are required only occasionally.
• Must be able to tolerate long periods of computer time a day.
• Ability to work shifts at various times of the day with additional on-call and weekend responsibilities.

Job: *Operations

Organization: *HF Administrative Plan Inc

Title: Clinical Ops Support Tech - Clinical Operations

Location: Florida - Brevard County-Rockledge

Requisition ID: 076184