Medical Services Coordination Specialist I

company•City of Utica, NY

3d•$20 - $33•Hybrid

About The Position

This position supports the workflow of the Medical Services division, providing support for programs within Behavioral Health, Quality Management, or Member Care Management. The role is responsible for adhering to regulatory requirements and assisting members in connecting with internal Health Plan resources, the Clinical Case Management team, and external community support systems.

Requirements

Minimum of one year experience working in an insurance company, medical assistant or Health Plan customer service, delivering care coordination at a community-based organization or working within a patient facing medical care setting required.
Working knowledge of medical terminology.
Demonstrated proficiency with Microsoft Office Suite.
Excellent oral and written communication skills.
Demonstrated organizational and interpersonal skills; able to manage multiple tasks under pressure.
Ability to utilize department specific applications and software: care management system and department libraries.
Ability to utilize engagement strategies to connect with population served (i.e. motivational interviewing, etc.).
Attention to detail.
Minimum of three years’ experience working in an insurance company, delivering care coordination at a Community Based Organization, or medical care setting required (Level II).
Ability to develop and apply in-depth knowledge of complex rules, such as care management systems and processes, departmental policies and procedures, product lines, and regulatory requirements (Level II).
Broad understanding of multiple areas of the company and willingness to develop collaborative solutions to achieve a better end-to-end process (Level II).
Ability to recognize sensitive issues and/or significant areas of concern and when to escalate to management (Level II).
Demonstrated ability to lead committee activities and support newer team members (Level II).
Consistently exceeding minimum productivity standards as set out by department (Level II).
Ability to find opportunities for process improvement and participate in resolution of more complex issues/activities (Level II).
Minimum of five years of experience working in an insurance company or medical care setting required (Level III).
Thorough knowledge and understanding of health plan contracts, regulatory requirements, and unit procedures (Level III).
Knowledgeable in multiple systems and/or processes that allow for effective and efficient identification of data or process issues to resolve related issues (Level III).
Ability to precept new staff, take on more complex challenges, flexibility and independence in work assignments, and participation in meetings and special projects (Level III).
Ability to identify process efficiencies and develop plan of action to implement (Level III).
Demonstrated presentation skills (Level III).

Responsibilities

Review and prep clinical cases for clinical staff.
Assess member’s needs by applying Health Plan approved case management guidelines and assessment tools, and make appropriate referrals to clinical programs.
Collaborate with the clinical care team to support enrollees, working with the enrollee/caregiver/legal guardian to identify and achieve shared treatment goals.
Manage a caseload productively and maintain appropriate documentation according to health plan standards.
Provide advocacy for members and their support systems, encourage self-sufficiency by addressing social determinants of health, providing effective coaching, and referring to case and disease management as needed.
Link enrollees with resources and empower them to use them to their advantage, ensuring referrals result in timely appointments.
Monitor member engagement and follow up on outstanding actions to ensure closure of care gaps and completion of required assessments.
Engage members via multiple communication channels (phone, messaging, digital tools) to support improved health outcomes.
Explore multiple sources of information to identify members who have a gap in care, aligning with HEDIS quality measures and Value Based Payment Programs.
Communicate effectively to provide outreach and education for members on healthcare quality metrics, assess barriers to care, and intervene as appropriate to assure access or facilitate referrals to other services for the purpose of improving healthcare (i.e. access to care, preventive health, chronic diseases, and health equity).
Coordinate enrollees’ access to transportation, pharmacy, grocery store, food pantry and other community resources, as needed, to meet care plan goals.
Prepare and assist in handling member and provider correspondence related to disease conditions and/or care management program services, ensuring accuracy and timeliness of processing.
Manage relevant BH/MCM/Quality voice and email inboxes and/or Stored Information retrieval (SIR) queues throughout the day for messages, potential care management referrals, and relevant clinical documentation.
Adhere to unit Service Level Agreements (SLA), internal and external regulatory commitments, and regulatory timeframes to meet the expectations of state partners.
Ensure the end-to-end process for care management referrals is accurate and complete by collaborating with other internal departments.
Perform non-care manager support staff duties such as requesting medical records, mailing educational materials, answering and responding to telephone calls, emails, etc., as long as they are non-clinical in nature.
Perform intake assessment and triage functions for each call to the appropriate MCM/Quality service area, providing 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.
Communicate to members and service providers according to regulatory agency requirements and/or organizational guidelines.
Consistently demonstrate high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct and Lifetime Way Values and Beliefs.
Maintain a high regard for member privacy in accordance with corporate privacy policies and procedures.
Regular and reliable attendance is expected and required.
Perform other functions as assigned by management.
Prioritize work and provide instruction, advice, and guidance to more junior staff as it relates to the assigned unit’s processes, procedures, and business systems (Level II).
Support training and onboarding of new staff (Level II).
Mentor newer staff and troubleshoot unit-related questions (Level II).
Serve as an intermediary between staff and management to alert leadership of potential barriers or challenges (Level II).
Review and bring forward recommendations to ensure desk level procedures and process workflows remain current and relevant (Level II).
Produce 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 (Level II).
Assist supervisor with control and monitoring of inventory levels of the assigned department, according to established priorities and performance standards (Level III).
Assist supervisor with monitoring and evaluating workflow to ensure timeliness and unit standards are met, providing reporting, analysis, and recommendations to unit management based on day-to-day and observed experience (Level III).
Assist in updating departmental policies, procedures, and desk level procedures relative to the department functions, identifying and developing processes and guidelines for performance improvement, productivity, and efficiency gains (Level III).
Handle complex issues, escalated customer questions, high maintenance or priority customers for the assigned business unit, and high dollar/high-cost member investigations (Level III).
Assess staff and unit training needs and report this information to the supervisor (Level III).
Identify eligibility and coverage and assist other staff and other areas within the company with related inquiries (Level III).
Collaborate with internal departments regarding changes in processes/systems and identify problems and recommend logical and effective solutions (Level III).