• Care Support Specialist I

    Location US-IA-Des Moines
    Job ID
    Clinical/Provider Support
    Requires Non-Compete?
  • Job Summary

    About the Role: We’re looking for a Care Support Specialist I to work within a call center setting facilitating care management functions, including membership and benefit verification and/or authorization, data collection, research, documentation of communications, and the accurate completion of precertification and notification requests. This individual will provide administrative support to care management teams and contribute to corporate and department objectives by processing incoming care management requests in a prompt, professional and courteous manner.


    About You: Are you excited about the opportunity to advocate for stakeholders through collaboration with multi-disciplinary teams? Are you able to manage a large variety of responsibilities while staying organized? Do you enjoy researching within guideline documentation and making decisions based on what you find? If you are a dedicated, customer-focused health care professional motivated and inspired by the opportunity to provide administrative support to care management teams in a fast-paced production environment, consider applying today!

    Minimum Qualifications Required (all must be met to be considered)

    • High School Diploma or GED
    • 1+ years of related experience including:
      • Customer or provider service experience, including experience developing customer relationships via telephone, obtaining necessary information and accurately documenting conversations
      • Health insurance or health care industry experience
    • Experience working within a production environment with production & quality metrics
    • Demonstrated ability to resolve issues and conflicts while maintaining composure and confidence
    • Attention to detail in obtaining complete, accurate information
    • Strong written and verbal communication skills with the ability to effectively communicate to varying audiences
    • Proficiency with Microsoft Office applications
    • Experience working in a team environment
    • Must be able to sit, answer continuous phone calls, and key for long periods of time

    Hiring Specifications Preferred

    • Associate’s Degree
    • Exposure to pre-service reviews
    • Medical office experience including knowledge of medical coding - e.g. ICD-9 or CPT
    • Knowledge of health care delivery systems, Wellmark products, or contract provisions


    Job Accountabilities

    a. Research and utilize knowledge of member eligibility, benefit coverage information, utilization management procedures/criteria and internal resource documents to accurately respond to care management requests.

    b. Verify provider network and participation status, including Blue Distinction Center status.

    c. Perform accurate, timely documentation of pertinent information received via phone, fax, or authorization tool. Ensure accuracy of information through strong communication skills and adherence to department guidelines.

    d. Review documentation and/or online resources and ensure provider submissions are complete.

    e. Support the nursing staff by setting up events in CCMS, ensure information submitted is complete, and process authorization requests in a timely manner. Create and send letters to providers and/or members to communicate authorization request outcomes. For health and care management requests that require further review, document the request and escalate to the appropriate review nurse.

    f. Demonstrate understanding and accurate interpretation of URAC and NCQA regulatory standards, H&CM guidelines, and HIPAA requirements to ensure accurate processing of files and protected health information compliance.

    g. Provide accurate information to customers by utilizing up to date tools and guidelines. Meet both quality assurance and production metrics established by the care management unit.

    h. Monitor and maintain email boxes on a regular basis to ensure that all inquiries are handled and dispersed to the appropriate staff in a timely manner.

    i. Comply with regulatory standards, accreditation standards and internal guidelines remains current and consistent with the standards pertinent to Utilization Management Services.

    j. Other duties as assigned.


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