Clinical Support Specialist - Utilization Management (CSS - UM)

Yamhill Community Care•McMinnville, OR

3d•Hybrid

About The Position

The Clinical Support Specialist - Utilization Management (CSS-UM) will work in-person and remotely to perform all aspects of the outlined utilization management (UM) support duties, receiving and processing authorization requests, claim reviews, triage, and case assignments. This position is responsible for administering assigned tasks, creating authorizations based on provider requests, collection and presentation of clinical documentation, and escalating identified member service request and issues. Working in collaboration and continuous partnership with clinical support staff, providers, and community resources in a team approach, to support the authorization and coverage of needed services that support positive health outcomes for YCCO members.

Requirements

Ability to assess a situation and seek or determine appropriate resolution, accept managerial direction, and feedback, and tolerate and manage stress.
Ability to use good judgment, takes personal initiative and uses discretion in performing job responsibilities including planning, prioritization, and organizational skills.
Ability to work efficiently as a member of a care team.
Ability to establish and maintain collaborative relationships with all levels of colleagues and the general public.
Ability to follow policy and procedure while working independently and to seek and offer assistance when needed.
Ability to work well with others, to hear and understand differing points of view, and to be able to articulate and explain situations based on perspective of client.
Highly proficient in spelling, grammar, and punctuation.
Knowledge of principles and procedures of record keeping and reporting.
Knowledge of rules regarding mandatory reporting.
Employees in this position may be subject to drug screening, as well as a physical and vaccination assessment.
Possess a high degree of initiative and motivation along with the ability to effectively collaborate and plan with others.
Excellent organizational skills including ability to handle multiple priorities and demands simultaneously in a dynamic work environment while maintaining high attention to detail and accuracy.
Ability to work independently, use sound judgment, anticipate next steps and be proactive as part of a diverse team within a Matrix or shared resources across departments work model.
Excellent computer skills, including Microsoft Windows, Word, Excel, and Outlook.
Ability to communicate both professionally and effectively in all forms of communication.
Ability to work in an environment with diverse individuals and groups.
Ability to remain flexible, positive, and adaptable.
Ability to work across the YCCO region and to work remotely, as needed.
Minimum two (2) years’ experience in healthcare setting including experience with case management, disease management, and/or quality improvement departments.
OR: Any combination of education and experience that would qualify candidate for the position.

Nice To Haves

Bilingual (English / Spanish).
Associates or Bachelors in Health related field.
Knowledge of Oregon Medicaid requirements, prior authorization and/or utilization review services.

Responsibilities

Coordinates and facilitates correct identification of patient status and benefit coverage per Oregon Medicaid guidelines.
Performs pre-authorizations, concurrent review, and post authorization request services necessary for adhering to administrative guidelines, policies, procedures, and timelines.
Ensures documentation meets State and Federal regulatory requirements for turn-around times, notification, and service authorization decisions.
Consults with providers, community partners, and colleagues to ensure all member requests are identified by the CCO.
Independently receives and processes incoming requests ensuring member identification, creation of service authorization requests, and clinical documentation is present.
Manages and processes case assignments for Clinical Peer Reviewers and Clinical Staff.
Maintains understanding of business rules and regulatory requirements pertaining to UM processes and operations.
Generates and creates community confidence in YCCO programs and services by embracing and exhibiting the Vision and Mission of YCCO.
Models excellent customer service for all inquiries, incoming calls, and decision routing to appropriate person/department in a respectfully and culturally appropriate manner.
Educates and ensures collaborative cross-setting communication among providers from all networks (physical, behavioral, dental, transportation, traditional health workers.)
Proactively establishes trusting relationships through regular contact and consulting with professionals in the areas of oral and behavioral health, pharmacists, primary care, etc.
Takes independent actions to address members’ identified needs including, but not limited to: Reviews and processes service authorization requests, ensures appropriate monitoring, evaluates and reports while making appropriate referrals both internally and externally to appropriate departments/resources.
Represents the Plan in facilitating cross-setting communication including clinic providers, community partners, and member support teams.
Tracks initial / concurrent service authorizations, denials, authorization gaps, and appeals status.
Self-assigns and completes tasks as they appear in the UM tasking queue.
Responds to all inquiries with a professional manner using Department guidelines.
Generates correspondence with clinical staff, providers, and members of the care team to meet turnaround time requirements.
Contributes to the creation of service authorization requests and the delivery of services as aligned with identified care needs under the direction of clinical care coordination staff.
Identifies and collects all required documentation as set forth by Federal, State, funding regulations, and Agency policy.
Serves as a Mandatory Reporter of suspected abuse of vulnerable populations as required by policy and regulation.
Maintains a high level of accuracy when processing and sharing information according to privacy regulations.
Protects clients and reduces YCCO risk by modeling and following policies, regulations, and requirements of Oregon Health Authority and YCCO.
Works to cultivate and develop inclusive and equitable services, and working relationships with diverse groups of employees, community partners, and community members.
Participates in the preparation and submission of regulatory and contract required deliverables.
Works closely with other YCCO departments, including Health Plan Operations and Compliance to assist with audits; including the External Quality Review (EQR), as needed.
Proposes and implements process improvements.
Meets deadlines for completion of assigned responsibilities and projects.
Maintains agreed upon work schedule with punctual, regular, and predictable attendance.
Attends in person Annual Company Conference in Oregon; typically held in the fourth week of September.
Demonstrates cooperation and teamwork using a professional and respectful demeanor.
Provides cross-training on specific job responsibilities.
Meets identified goals that contribute to departmental goals.
Works collaboratively in a team and matrixed (cross-department) environment with a spirit of cooperation.
Respectfully takes direction from Supervisor.
Performs other duties as assigned.