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Clinical Services Coordinator, Intermediate

  • Job
    Full-time
    Mid Level
  • Healthcare
  • San Diego, +2

AI generated summary

  • You need 3+ years of experience in UM, understanding of TAT standards, and familiarity with prior authorization guidelines, particularly in pediatric care.
  • You will process authorizations, support case managers, input data, research eligibility, and provide administrative support for healthcare services at Blue Shield of California.

Requirements

  • Requires basic job knowledge of systems and procedures obtained through prior work experience or education.
  • Typically, requires minimum of 3 years of experience. May require vocational or technical education in addition to prior work experience.
  • Requires UM regulatory TAT standards
  • Requires basic job knowledge of systems and procedures obtained through prior work experience or education
  • At least 1 year work experience within the Medical Care Solutions Utilization Management Department or a similar medical management department at a different payor, facility, or provider group
  • In-depth knowledge of the prior authorization and/or concurrent review non-clinical business rules and guidelines, preferably within the inpatient, DME and/or Home Health areas related to children

Responsibilities

  • Process faxed/phoned in authorizations, UM/CM requests and/or calls left on voicemail
  • Select support for Case Manager such as mailings, surveys
  • Data entry including authorization forms, high risk member information, verbal HIPPA authorizations information for case creation
  • Support to Advanced/Specialist CSC
  • Assign initial EOA days, or triage to nurses, based on established workflow
  • Research member eligibility/benefits and provider networks
  • Provide operational support to ensure healthcare services are provided to member, employer, and providers
  • Serve as the initial point of contact for members and providers by telephone or correspondence
  • Within extension of authority, review specific CHP eligibility referrals
  • Process service authorization referrals and assist with system letters, requests for information and data entry
  • Provide administrative/clerical support to medical management

FAQs

What are the primary responsibilities of the Clinical Services Coordinator, Intermediate in the Children’s Health Program team?

The Clinical Services Coordinator, Intermediate is responsible for processing faxed/phoned in authorizations, conducting data entry, researching member eligibility/benefits and provider networks, providing operational support for healthcare services, serving as the initial point of contact for members and providers, reviewing specific CHP eligibility referrals, processing service authorization referrals, and providing administrative/clerical support to medical management.

What level of experience is required for the Clinical Services Coordinator, Intermediate position?

The position typically requires a minimum of 3 years of experience. A vocational or technical education in addition to prior work experience may be required. Additionally, at least 1 year 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 is preferred.

What knowledge and skills are necessary for success in this role?

The ideal candidate should have a basic understanding of systems and procedures related to medical management obtained through prior work experience or education. Familiarity with UM regulatory TAT standards, prior authorization and/or concurrent review non-clinical business rules and guidelines, and proficiency in processing medical records and requests in alignment with nationally recognized standards are also important.

What is the reporting structure for the Clinical Services Coordinator, Intermediate role?

The Clinical Services Coordinator, Intermediate will report to the Children’s Health Program (CHP) Manager within the Promise Clinical Team. They will work closely with clinical staff to support member needs using established and approved Blue Shield Medical Policies and Guidelines.

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Finance
Industry
5001-10,000
Employees
1939
Founded Year

Mission & Purpose

Blue Shield of California strives to create a healthcare system worthy of its family and friends that is sustainably affordable. Blue Shield of California is a tax-paying, nonprofit, independent member of the Blue Shield Association with 4.7 million members, 7,800 employees, and $22.9 billion in annual revenue. Founded in 1939 in San Francisco and now headquartered in Oakland, Blue Shield of California and its affiliates provide health, dental, vision, Medicaid and Medicare healthcare service plans in California. Blue Shield of California complies with applicable state laws and federal civil rights laws, and does not discriminate on the basis of race, color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age, or disability.