Job Description

Job Title: Clinical Service Rep I
Job ID: 180000XR
Status: Full-Time
Regular/Temporary: Regular
Shift: Day Job
Facility: UPMC Health Plan
Department: UM Clin Ops
Location: 600 Grant St, Pittsburgh PA 15219


UPMC Health Plan's Clinical Operations team is seeking a Clinical Service Representative I!

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.


This is a Monday through Friday, daylight role in the US Steel Tower.


Along with this permanent opportunity, this team is also actively seeking temporary assistance.  


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


  • High School Graduate
  • One (1) year of customer service or call center experience required
  • One (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:
    UPMC is an equal opportunity employer. Minority/Females/Veterans/Individuals with Disabilities

Salary Range: $14.53 to $22.86 / hour

Union Position: non union

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