Our Mission is to Make Healthcare Right. Together. Built upon the belief that by connecting and aligning the best local resources in healthcare delivery with the financing of care, we can deliver a superior consumer experience, lower costs, and optimized clinical outcomes.
What drives our mission? The company values we live and breathe every day. We keep it simple: Be Brave. Be Brilliant. Be Accountable. Be Inclusive. Be Collaborative.
If you share our passion for changing healthcare so all people can live healthy, brighter lives – apply to join our team.
SCOPE OF ROLE
The Associate Representative, Clinical supports the Utilization Management team through non-clinical referral activities and clerical assistance. The organization limits use of non-clinical administrative staff for acquisition of structured clinical data.
The Associate Representative, Clinical job description is intended to point out major responsibilities within the role, but it is not limited to these items.
- Provides data entry, filing, tracking time frames and status of case files and providing written and verbal notification of determination to members and providers.
- Prepares necessary documentation for utilization management and appeals processes, performs data management and coordinates communication between members of the UM and Appeals teams to ensure timely follow through.
- Assist in setting up communications with payors and/ or physicians as applicable, including the use of fax and phone calls.
- Perform review of service request for completeness of information
- Collection of and transfer of non-clinical data
- Reviews providers' requests for services and coordinates utilization/appeals management review.
- Notifies Department Leadership of potential missed timeframes for submission and follow-up on responses and escalates cases as appropriate.
- Serves as a liaison between patient account services, physicians, care coordinators, Utilization and Appeals Managers, physician advisors and facility departments.
- Other duties and responsibilities as assigned.
EDUCATION, TRAINING, AND PROFESSIONAL EXPERIENCE
- High School Diploma required; Associate or Bachelors’ Degree preferred
- Medical Assistant experience preferred
- Three (3) or more years of healthcare industry experience preferred
- Working knowledge and understanding of basic utilization management concepts preferred
- Prior working experience at a health plan preferred
- Must possess strong organizational and prioritization skills and competence and capacity to handle multiple initiatives while managing conflicting priorities.
- Excellent written and verbal communication skills.
- Able to keep an open line of communication with manager and awareness of situations that need to be escalated.
- Must be self-motivated, able to take initiative, and ability to thrive and drive results in a collaborative environment.
- Experience in using the Microsoft Office Suite including Excel and Word as well as demonstrated ability to learn/adapt to other computer-based systems and tools.
The majority of work responsibilities are performed in an open office setting, carrying out detailed work sitting at a desk/table and working on the computer. Travel may be required.
We’re Making Healthcare Right. Together.
We understand patient pain points, eliminating complexity while increasing transparency, for greater access and easier navigation.
We integrate and align individual incentives at all levels, from financing to optimization to delivery of care.