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Job Family Description
Positions in this family include those reposnsible for functions in areas such as health services, clinical services and delivery of clinical care.
Job Function Description
Positions in this function includes those responsible for initial triage of members, administrative intake of members or managing the admission/discharge information post-notification, working with hospitals and the clinical team. Includes managing incoming calls, managing requests for services from providers/members, providing information on available network services and transferring members as appropriate to clinical staff. Manages the referrals process, processes incoming and outgoing referrals, and prior authorizations. This function includes intake, notification and census roles.
General Job Profile
– Moderate work experience within own function.
– Some work is completed without established procedures.
– Basic tasks are completed without review by others.
– Supervision/guidance is required for higher level tasks.
Job Scope and Guidelines
– Applies knowledge/skills to activities that often vary from day to day.
– Demonstrates a moderate level of knowledge and skills in own function.
– Requires little assistance with standard and non-standard requests.
– Solves routine problems on own.
– Works with supervisor to solve more complex problems.
– Prioritizes and organizes own work to meet agreed upon deadlines.
– Works with others as part of a team
Minimum Educational Background
– High school education or equivalent experience.
Functional Competency & Description Proficiency
Level CLA_Receive Medical/Behavioral/Clinical Services or Benefits Requests C) Fully Proficient
-Serve as primary point of contact for providers or members regarding medical/behavioral/clinical services or benefits
-Extract and review fax requests for medical or clinical services
-Receive calls requesting medical/behavioral/clinical services or benefits information (e.g., from providers or members) -Receive electronic referral form requests for medical/behavioral/clinical services
-Utilize phone system to respond to and transfer calls to appropriate individuals
-Ask callers standard questions to understand requests, gather necessary information, and assess urgency
-Access electronic member files using policy or id number -Determine member eligibility
-Follow protocols to task requests appropriately
-Check procedure codes against notification requirements and benefit coverage to determine next steps -Reference automated job aid tools via the computer to identify appropriate procedures when needed
CLA_Research Information to Respond to Medical/Behavioral/Clinical Services or Benefits Re C) Fully Proficient
-Access claims information -Review and interpret call history documentation (e.g., case notes)
-Navigate between computer screens and platforms to research information (e.g., medical, clinical, or benefits information)
-Take calls and questions from members and/or providers regarding case status
-Determine whether authorizations are required for requested medical services
-Reference automated job aid tools via computer to research relevant rules, regulations, or procedures
-Learn computer system and process changes and updates and incorporate into daily work -Contact internal resources if necessary to clarify information
-Identify appropriate resource (e.g., doctor, resource, contracted provider) to respond to medical requests
CLA_Process Medical/Behavioral/Clinical Services or Benefits Requests C) Fully Proficient
-Provide/explain benefit information to members/providers -Provide/explain authorization information to members/providers
-Communicate with clinical team to ensure provider receives a response when necessary
-Document call history information into relevant computer system
-Enter medical request data into relevant computer system -Follow standard procedures to complete requests
-Request medical review via relevant computer system as needed
-Review and advise member/provider of status of a request (e.g., notification, authorization)
-Schedule appointments for members based on request
-Provide information regarding appointments and medical services to facilities staff to assist members
Job Family Description
Positions in this family include those reposnsible for functions in areas such as health services, clinical services and delivery of clinical care.
Job Function Description
Positions in this function includes those responsible for initial triage of members, administrative intake of members or managing the admission/discharge information post-notification, working with hospitals and the clinical team. Includes managing incoming calls, managing requests for services from providers/members, providing information on available network services and transferring members as appropriate to clinical staff. Manages the referrals process, processes incoming and outgoing referrals, and prior authorizations. This function includes intake, notification and census roles.
General Job Profile
– Moderate work experience within own function.
– Some work is completed without established procedures.
– Basic tasks are completed without review by others.
– Supervision/guidance is required for higher level tasks.
Job Scope and Guidelines
– Applies knowledge/skills to activities that often vary from day to day.
– Demonstrates a moderate level of knowledge and skills in own function.
– Requires little assistance with standard and non-standard requests.
– Solves routine problems on own.
– Works with supervisor to solve more complex problems.
– Prioritizes and organizes own work to meet agreed upon deadlines.
– Works with others as part of a team
Minimum Educational Background
– High school education or equivalent experience.
Functional Competency & Description Proficiency
Level CLA_Receive Medical/Behavioral/Clinical Services or Benefits Requests C) Fully Proficient
-Serve as primary point of contact for providers or members regarding medical/behavioral/clinical services or benefits
-Extract and review fax requests for medical or clinical services
-Receive calls requesting medical/behavioral/clinical services or benefits information (e.g., from providers or members) -Receive electronic referral form requests for medical/behavioral/clinical services
-Utilize phone system to respond to and transfer calls to appropriate individuals
-Ask callers standard questions to understand requests, gather necessary information, and assess urgency
-Access electronic member files using policy or id number -Determine member eligibility
-Follow protocols to task requests appropriately
-Check procedure codes against notification requirements and benefit coverage to determine next steps -Reference automated job aid tools via the computer to identify appropriate procedures when needed
CLA_Research Information to Respond to Medical/Behavioral/Clinical Services or Benefits Re C) Fully Proficient
-Access claims information -Review and interpret call history documentation (e.g., case notes)
-Navigate between computer screens and platforms to research information (e.g., medical, clinical, or benefits information)
-Take calls and questions from members and/or providers regarding case status
-Determine whether authorizations are required for requested medical services
-Reference automated job aid tools via computer to research relevant rules, regulations, or procedures
-Learn computer system and process changes and updates and incorporate into daily work -Contact internal resources if necessary to clarify information
-Identify appropriate resource (e.g., doctor, resource, contracted provider) to respond to medical requests
CLA_Process Medical/Behavioral/Clinical Services or Benefits Requests C) Fully Proficient
-Provide/explain benefit information to members/providers -Provide/explain authorization information to members/providers
-Communicate with clinical team to ensure provider receives a response when necessary
-Document call history information into relevant computer system
-Enter medical request data into relevant computer system -Follow standard procedures to complete requests
-Request medical review via relevant computer system as needed
-Review and advise member/provider of status of a request (e.g., notification, authorization)
-Schedule appointments for members based on request
-Provide information regarding appointments and medical services to facilities staff to assist members
