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BCBSMA is seeking a new Clinical Intake Specialist to join the elite Utilization Management Division!

The Clinical Intake Specialist (Customer Service) is an integral part of Utilization Management, processing telephonic and fax notifications, referrals, and requests for authorization from members, facilities, and physician offices. The Clinical Intake Specialist (Customer Service) utilizes organizational and communication skills, principals of managed care, knowledge of regulatory requirements, and collaborative interactions with the clinical reviewers and provider community to facilitate efficient and timely requests.

The Clinical Intake Specialist (Customer Service) focuses on building and updating referrals and authorization requests in the member record that are essential to conducting the review process and enabling accurate and timely claims payment. The Clinical Intake Specialist (Customer Service) works primarily by fax and telephone to ensure that all necessary information is received so that an optimal review can be conducted by a team clinician. The Clinical Intake Specialist (Customer Service) demonstrates an understanding of regulatory requirements, principals of managed care and department business goals and objectives.

KEY RESPONSIBILITIES:
- Verify member eligibility, collect demographic and pertinent clinical information, and document results in the computer system
- Build cases in the computerized member record using information gathered from faxes and/or phone calls
- Document of information using department standards of documentation
- Communicate with providers regarding the assigned DRG, and/or any necessary decision data.
- Assign accurate codes to all diagnoses and procedures and the DRG, recoding, and updating cases when applicable.
- Communicate with the Clinical Review team to ensure continuity of the notification, coding, and review processes.
- Manage of workload within regulatory turnaround time requirements and mandated timeframes for processing cases
- Handle protected health information consistent with department and company policies and regulatory requirements
- Assist in refinement and implementation of unit workflows to enhance efficiency and support unit/department goals
- Assist implementation of all new utilization management processes and programs in accordance with business plans to provide quality customer service to all customers;
- Engage in cross-training to develop the variable skills necessary to support all team responsibilities
- Other duties as assigned

QUALIFICATIONS & SKILLS:
- Dealing w/ambiguity (Demonstration of insight, self-direction and self-discipline)
- Flexibility/ Adaptability (Coping) (a calm demeanor, ability to understand changing situations, ability to accomplish job tasks under shifting conditions, ability to meet new expectations or quickly learn new job tasks)
- Critical thinking / problem solving skills (ability to analyze information to construct effective solutions)
- Execution and results (ability to set goals, follow processes, meet deadlines, and deliver expected outcomes with appropriate sense of urgency)
- Communication (ability to articulate complex concepts, verbally and in writing, in decisive and focused manner, with professional and engaging tone)
- Building effective relationships (ability to establish and maintain productive partnerships, internally and externally, in person and virtually, in order to facilitate professional and business goals)
- Cultural competence (demonstration of awareness, attitude, knowledge, and skills to work effectively with a culturally and demographically diverse population)
- Managed Care and health care landscape insight (nuanced understanding of products, benefits, healthcare delivery system, accreditation and regulatory requirements, and community resources)
- Business Insight (Demonstrates an understanding of the utilization management process and its business implications, and awareness of current / future policies, practices, trends, and information affecting the business and organization)
- Comfort and proficiency with the use of computers and technology (ability to work within multiple computer and telephone applications and systems; ability to key in data proficiently and in real time during a phone call; comfort quickly learning and effectively working within a variety of media)
- Focus (ability to identify and manage to key, high-leverage information, tasks, and events)
- Consistency (ability to follow identified workflows, plan requirements, clinical guidelines, and make sound, objective decisions)
- Negotiation (ability to resolve disputes and craft outcomes that address competing interests while achieving business objectives
- Call management (ability to conduct telephone conversations that ensure value in every contact, achieve the desired objectives for placing the call, and are efficient and professional)
- Productivity (ability to prioritize and manage assigned workload to accomplish full slate of targeted activities)

EDUCATION & RELEVANT EXPERIENCE:
- Associate's degree preferred, high school or equivalent diploma required
- Working knowledge of DRG assignment, human anatomy and physiology, clinical disease processes and medical terminology strongly preferred
- Microsoft Office skills a plus
- Previous experience in a medical/clinical setting preferred
- Customer service training or previous Call Center experience highly desired

LocationQuincyTime TypeFull time

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Blue Cross Blue Shield of Massachusetts is an Equal Employment / Affirmative Action Employer. Applicants are considered for all positions without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or expression, or any other characteristics protected by law.