Gold Kidney Health Plan
GOLD KIDNEY CORE VALUES:
Gold Kidney Health Plan is a people business. Our success depends on having the best and brightest employees and helping them attain their personal and professional goals while delivering excellence in patient care and business results. Our employees embody our culture, which is based on six core values supporting our promise to improve the quality of life of every patient every day. These core values are Patients and Partners First, Honesty and Integrity, Quality and Compliance, Collaboration, No-Limits Mindset and Results Oriented.
Purpose and Scope:
The Clinical Coordinator is responsible for intake of all requests for medical services, both pre-service, concurrent, and retro reviews. The incumbent will use set criteria, approving specific services within the related UM and CM system. The incumbent will work and facilitate workflow duties to assist the UM,CM and Medical Coordination teams administratively.
Principal Duties and Responsibilities:
- Coordinate medical and non-medical services for members as needed
- Ensure prompt accurate data entry of authorization requests into the system received via email, phone, or fax
- Utilize knowledge and experience to analyze contractual or administrative issues related to the requests
- Be a primary resource between Customer Service and the Clinical Services Team
- Assist in member and provider phone calls to assist the clinical team
- Take inbound and make outbound calls and participate in the phone queue
- Identify additional information needed and request it when appropriate
- Accurately identify when and how to refer cases to appropriate clinical personnel or take other actions
- Follow strict guidelines to ensure all work meets corporate standards for accuracy, timeliness, quality, and compliance with federal, state and accreditation regulations
- Maintains records both electronically and hard file working closely with clinical teams.
- Coordinate with customer service and the clinical services staff
- Communicate with internal and external customers i.e., members, providers, vendors, employees
- Consistently meet department productivity and performance metrics.
- Contribute to the efficiency of the department by being flexible and cross-trained in other functions
- Review and comply with the Code of Business Conduct and all applicable company policies and procedures, local, state, and federal laws, and regulations
- Escalates issues to supervisor for resolution, as deemed necessary
- Assist with various projects as assigned by direct supervisor
- Responsibilities could include focus on other departments and are not limited to clinical management teams when needs arise
- Other duties as assigned
Physical Demands and Working Conditions:
- The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- This is a hybrid role, office time is required.
- High School Diploma required.
- Graduate of Medical Assistant program; Medical Assistant certification preferred.
Experience and Required Skills:
- 1 – 2 years’ related experience.
- Familiarity with insurance billing and/or terminology preferred.
- Managed Care experience, preferred.
- Call Center experience preferred.
- Medicare and Medicaid experience preferred.
- Customer Service experience preferred.
- Knowledge of CPT and ICD codes preferred.
- Strong data entry skills preferred.
- Excellent interpersonal skills including excellent verbal and written communication skills
- Ability to cope in a fast-paced production environment and to effectively utilize multiple systems to perform function
- Demonstrated knowledge of customer service skills when responding to questions and other inquiries from internal and external customers
- Strong computer skills with demonstrated proficiency in word processing, spreadsheet, database, presentation, and email applications.
- Must be organized and detail oriented with a strong bias for follow-up and problem resolution
|Job Category||Clinical Services|