Clinical Specialist – Nonclinical
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Job Description
Remote Clinical Specialist supporting Cambia’s health care system through nonclinical utilization management case research, documentation, provider outreach, and regulatory compliance.
Responsibilities:
- Research simple to moderately complex requests and documentation related to utilization management processes and regulatory requirements
- Review requests for completeness, obtain missing information, and prepare cases for clinical review
- Complete nonclinical case tasks, including documenting critical information, initiating referrals, and accurately closing cases
- Conduct telephonic and written outreach to providers to request medical records and communicate case determinations, cancellations, and other information
- Manage time and follow guidelines to meet timeliness, production, quality, accuracy, federal, state, BCBSA, and accreditation standards
- Communicate across teams and maintain organized access to reference materials, policies, and procedures
- Uphold a professional, ethical, member-focused work environment
- Identify workflow and system improvement opportunities
- Assist with systems testing, coordinate case information in external vendor systems, or discuss service planning with providers
Requirements:
- High school diploma or equivalent and 2 years of clinical or hospital experience, or equivalent combination of education and experience
- LPN, CMA or CNA preferred
- Clinical experience, preferably in a hospital or health plan clinical services setting
- Strong oral and written communication skills
- Ability to work in a fast-paced environment while maintaining accuracy, confidentiality, and customer focus
- Intermediate computer skills, including Microsoft Office, Outlook, and Internet search
- Experience with health care systems and documentation, including EMR, billing, and claims
- Knowledge of medical terminology, anatomy, and coding (CPT, DX, HCPCs)
- Strong organization, data entry, and administrative skills
- Ability to investigate and research complex UM case work issues and use critical thinking
- Ability to work independently, prioritize work, meet deadlines, and achieve operational standards
- Ability to work effectively in a team environment
- Ability to perform UM Clinical Specialist duties and responsibilities
- Ability to mentor coworkers and train new team members
- Experience with AI tools and technologies highly desired
- Personal mobile device required for MFA
- Wired internet connection required; satellite or cellular internet is not accepted
- Minimum internet speed of 5Mb upload and 10Mb download
- Background check required
Benefits:
- 5% bonus target
- Medical, dental and vision coverage for employees and eligible family members, including mental health benefits
- Annual employer contribution to a health savings account
- Generous paid time off
- 10 company-paid holidays
- 401(k) company match
- Potential discretionary retirement contribution based on company performance, with no vesting period
- Up to 12 weeks of paid parental time off after 12 months of continuous service
- Wellness programs that reward participation
- Employee Assistance Fund
- Commute and parking benefits
- Work from home option
- Flexible work option requiring wired internet service with minimum upload/download speeds
- Company-supported outreach programs
- Employee resource groups
- Competitive base pay
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