Description

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

This role is eligible for work-from-home opportunities based on performance and to managements discretion. 

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.

Responsibilities:

• 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

Qualifications

• 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

Total Rewards

More than just competitive pay and benefits, UPMC’s Total Rewards package cares for you in all areas of life &emdash; because we believe that you’re at your best when receiving the support you need: professional, personal, financial, and more.

Our Values

At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.