Clinical Service Representative I

UPMC Health Plan is hiring a Clinical Service Representative I to join the UM CM Operations team. This position will predominantly work remotely and will work standard daylight hours, Monday through Friday (schedule will fall between the hours of 8 am - 5 pm). 

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. 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.

Must be legally authorized to work in the United States, without requiring, now or in the future, sponsorship for employment visa status. UPMC does not participate in STEM OPT.


Responsibilities:
 

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

• 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