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Clinical Service Representative I

  • Job ID: 357589311
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours: 12 pm to 8 pm
  • Shift: Evening Job
  • Facility: UPMC Health Plan
  • Department: UM CM Operations
  • Location: 600 Grant St, Pittsburgh PA 15219
  • Union Position: No
  • Salary Range: $15.88 to $24.98 / hour

Description

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

This shift will be 12 pm to 8 pm Monday through Friday and will work from home. 

The Clinical Service Representative I 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. The clinical Service Representative I will also provide non-clinical support for the Medical Management activities by serving as the first line of contact for utilization management activities.

Responsibilities:

 

  • Initiate assessments on members by obtaining all necessary member demographics and any available clinical information
  • Perform callbacks 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
  • Facilitate transportation needs

Qualifications

  • 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:

UPMC is an Equal Opportunity Employer/Disability/Veteran

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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.

   Current UPMC employees must apply in HR Direct