Clinical Specialist (nonclinical)
About The Position
The Clinical Specialist is a nonclinical member of Cambia’s Clinical Operations team. The role supports utilization management (UM) operations by handling nonclinical tasks, helping meet regulatory requirements, supporting key initiatives, and contributing to staffing coverage. This work helps free registered nurses to focus on clinical responsibilities and increases overall operational capacity. The position uses clinical knowledge and critical thinking to research requests and documentation, prepare cases for clinical review, and manage case information accurately. It also involves obtaining missing information, communicating with providers, and completing case tasks in accordance with departmental, regulatory, and quality standards. The role is work-from-home within Idaho, Oregon, Utah, and Washington; employees must have a wired, non-satellite, non-cellular internet connection meeting the stated speed requirements, and a personal mobile device for multifactor authentication. Preference is given to current employees and candidates residing in Idaho or Utah.
Requirements
- High school diploma or equivalent and two years of clinical or hospital experience, or an equivalent combination of education and experience.
- 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 focus on customer needs.
- Intermediate computer skills, including Microsoft Office, Outlook, and internet search, and experience with health care systems and documentation such as EMR, billing, and claims.
- Knowledge of medical terminology, anatomy, and coding, including CPT, DX, and HCPCs.
- Strong organization, data entry, and administrative skills.
- Ability to investigate and research complex issues and inquiries related to UM case work, apply critical thinking, and work with clinical staff to resolve them.
- Ability to work independently, prioritize work, meet deadlines, and achieve operational standards.
- Ability to work effectively in a team environment.
- Ability to perform the duties and responsibilities of a UM Clinical Specialist.
Nice To Haves
- LPN, CMA, or CNA credential.
- Experience with AI tools and technologies to enhance productivity and decision-making in professional settings is highly desired.
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 closing cases accurately.
- Conduct telephone and written outreach to providers to request medical records and communicate case determinations, cancellations, and other information in compliance with regulatory and quality requirements.
- Manage time and follow established guidelines to meet standards for timeliness, production, quality, and accuracy, as well as federal, state, BCBSA, and accreditation requirements.
- Communicate effectively within and across teams; maintain organized access to reference materials, policies, and procedures; and uphold a professional, ethical, member-focused work environment.
- Identify workflow and system improvement opportunities and support continuous improvement.
- Assist with systems testing, coordinate case information in external vendor systems, or discuss service planning with providers as needed.
- Mentor and support coworkers and provide training to new team members.
Benefits
- Medical, dental, and vision coverage for employees and eligible family members, including mental health benefits.
- Annual employer contribution to a health savings account.
- Paid time off varying by role and tenure, in addition to 10 company-paid holidays.
- 401(k) plan with company match and potential discretionary contribution based on company performance, with no vesting period.
- Up to 12 weeks of paid parental time off, subject to eligibility requirements.
- Wellness programs that reward participation.
- Employee Assistance Fund.
- Commute and parking benefits.
- Bonus opportunities; the stated bonus target is 5%.
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What This Job Offers
Job Type
Full-time
Education Level
High school or GED
