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Job Description:

Summary:

This position supports the workflow of the Medical Services division. Depending on the specific tasks assigned, the Medical Services Coordination Specialist provides administrative support for any of the programs of Utilization Management, Behavioral Health, Quality Management, or Member Care Management. This position acts as a resource for staff regarding members' specific contract benefits, consistent with products, policies and procedures and related health plan functions such as member services, claims, and the referral process. As well as functions related to legislative and federal regulatory mandates related to the Health Plan

Essential Primary Responsibilities/Accountabilities:

All Levels:

Level I:

• Review / prep clinical case for clinical staff.
• Navigates and utilizes corporate applications; core claims and membership system, intranet and related links to provide support to the division.
• Serves as the primary contact for providers regarding authorization, information requests, claim inquiries and benefits. Provides triage assistance to internal subject matter experts, as needed.
• Prepares and assists in handling member and provider correspondence related to authorization detail, disease conditions and/or care management program services. Assures accuracy and timeliness of processing.
• Provides timely response to all research inquiries from other departments and assures the response is thorough and accurate.
• Assesses benefit coverage, interpreting individual eligibility, provider and subscriber agreement parameters, and required criteria.
• Validates relevant UM/BH/MCM/Quality voice and email inboxes and/or Stored
• Information retrieval (SIR) queues throughout day for messages, potential care management referrals, authorization requests and clinical documentation
• Coordinates with staff to ensure consistent policy and procedures and customer experience across regions.
• Facilitates adherence to unit Service Level Agreements (SLA), internal and external regulatory commitments.
• FEP specific: functions assigned to non-care managers are monitored by the care manager
• The care manager provides feedback to the non-care manager's supervisor, as needed, at the time of the annual performance review
• Non-care manager support staff duties may include:
• Requesting medical records
• Faxing materials
• Mailing of educational materials
• Answering and responding to telephone calls, e-mails, etc. as long as they are non-clinical in nature
• Other non-clinical duties as assigned
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of
• Conduct, and leading to the Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Level II (in addition to Level I essential responsibilities/accountabilities):

• Prioritizes work and provides instruction, advice and guidance to more junior staff as it relates to the assigned unit's processes, procedures, and business systems.
• Collaborates with junior level staff and is a positive influence within a team unit structure
• Serves as an intermediary between staff and management to alert supervisor of potential problems.
• Collaborates with other key departments (Claims, Customer Service, related care management units) to ensure end-to-end process for authorizations and care management referrals is accurate and complete.
• Performs intake assessment and triages functions for each call to appropriate
• UM/BH/MCM/Quality service area. Provides preliminary support to multiple levels of providers (and others as needed), including but not limited to physicians, skilled nursing facilities, mid-level providers and members
• Extracts, sorts and distributes reports from databases, both internal and external, including but not limited to Kaleida, Catholic Health System, internal data bases as determined based on designated criteria to other Care Coordination staff for review and screening
• Use a systematic approach to identify members who would benefit from care management or have previous UM/BH activity, and applies care management criteria to determine member appropriateness for care management programs (systems researched may include: care management system, claims and membership system, MedAi); researches claims history and related services (medication refills, identification of in and out of network providers, etc.).
• Communicates to the members and service providers according to regulatory agency requirements and/or organizational guidelines; schedules initial telephone call appointments with members and care managers, as requested
• Produces care management statistics on a daily and as needed basis for department related metrics: case and review timeliness, workflow volumes, referrals generated to care management programs
• Provides administrative support to the grievance and appeals process within the
• Medical Services department

Level III (in addition to Level II essential responsibilities/accountabilities):

• Assists supervisor with control and monitoring of inventory levels of assigned department (including but not limited to authorizations, claims, care management referrals) according to established priorities and performance standards.
• Assists supervisor with monitoring and evaluating workflow to ensure timeliness and unit standards are met. Provides reporting, analysis and recommendations to unit management based on day-to-day and observed experience.
• Assists in updating departmental policies, procedures and desk-top manuals relative to the department functions. Identifies and develops administrative processes and guidelines for performance improvement.
• Handles complex issues, escalated customer questions, high maintenance or priority customers for the assigned business unit, high dollar/high cost member investigation.
• Assists with staff development through mentoring and troubleshooting of unit- related questions. Assesses staff and unit training needs and reports this information to the supervisor.
• Collaborates with other key departments (Claims, Customer Service, related care management units) regarding changes in processes/systems and identifies problems and recommends logical and effective solution.

Minimum Qualifications:

NOTE: We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.

All Levels:

Level I:

• LPN, Medical Assistant, Health Plan customer service or claims processor experience with a minimum of one year experience working in an insurance company or medical care setting required.
• Working knowledge of medical terminology and the claims systems required.
• Must demonstrate proficiency with Microsoft Office Suite, internet browsers and document creation.
• Excellent oral and written communication skills.
• Demonstrates organizational and interpersonal skills; able to manage multiple tasks under pressure.
• Demonstrates proficiency in basic navigation and utilization of department specific applications: care management system, department libraries.
• Demonstrates role-specific competencies as it pertains to their work unit on a consistent basis.
• Attention to detail.

Level II (in addition to Level I essential responsibilities/accountabilities):

• Ability to develop and apply in-depth knowledge of complex rules, such as those of the authorization process, care management systems and processes, FEP reporting processes/rules including departmental policies and procedures, product lines, and contract benefits and a minimum of three years' experience working in an insurance company or medical care setting required.
• A broader understanding of multiple areas of the company and willingness to develop collaborative solutions to achieve a better end-to-end process
• Ability to recognize sensitive issues and/or significant areas of concern and when to escalate to management
• Demonstrates an ability to lead committee activity

Level III (in addition to Level II essential responsibilities/accountabilities):

• A minimum of five years of experience working in an insurance company or medical care setting required. In lieu of five years of experience, a minimum of three years of experience working in an insurance company or medical care setting and active Certified Professional Coder (CPC) credential.
• Demonstrates a thorough knowledge and understanding of sources of information about health plan contracts, riders, policy statements, and procedures in order to identify eligibility and coverage and assisting other staff and other areas within the company with related inquiries.
• Knowledgeable in multiple systems and/or processes that allow for effective and efficient identification of data or process issues as related to the roles/responsibilities of the position and participation in resolution of the same.
• Active demonstration of broad knowledge base and positive work habits as evidenced by ability to precept new staff, take on new challenges, flexibility in work assignments, and participation in meetings and projects as assigned.
• Demonstrated presentation skills.

Physical Requirements:

• Position requires working at a stationary desk, on a computer for a majority of the day.

**

The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.

Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.

OUR COMPANY CULTURE:

Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s):

Level I: Grade 108: Minimum $18.55 - Maximum $26.90

Level II: Grade 109: Minimum $19.22 - Maximum $30.76

Level III: Grade 110: Minimum $20.02 - Maximum $33.03

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position's minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Please note: There may be opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team. This decision is made on a case-by-case basis.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

Equal Opportunity Employer - minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity

Minimum Salary: 0.00 Maximum Salary: 0.00 Salary Unit: Yearly