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UPMC continues to comply with governmental guidance related to local, state, and federal COVID-19 vaccination for employment. All employees and affiliated staff of UPMC entities are considered essential health care workers and will be accountable to follow the Centers for Medicare & Medicaid Services (CMS) federal vaccine mandate. To be compliant with the federal mandate, employees must complete the approved vaccination dosage regimen currently defined by the federal government. Compliance with the federal mandate is encouraged before hire and is required after employment begins. Medical and religious exemption requests may be submitted for consideration.

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   Current UPMC employees must apply in HR Direct

Clinical Service Representative I

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. Hours will vary for this position and will range from 8 am to 8 pm Monday through Friday. 

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:

 

  • Facilitate transportation needs
  • 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
  • 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

 

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 spreadsheet 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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   Current UPMC employees must apply in HR Direct