Clinical Specialist – Nonclinical

This is a fully remote position, open to applicants in Idaho, +3 more states.

📋 Description

• Investigate straightforward to moderately intricate requests and documentation concerning utilization management processes and regulatory standards.

• Assess requests for thoroughness, acquire any missing details, and prepare cases for clinical evaluation.

• Execute nonclinical case responsibilities, such as documenting essential information, initiating referrals, and accurately finalizing cases.

• Conduct both telephonic and written outreach to providers to request medical records and convey case decisions, cancellations, and additional information.

• Efficiently manage time and adhere to guidelines to achieve timeliness, production, quality, accuracy, and compliance with federal, state, BCBSA, and accreditation standards.

• Facilitate communication across teams and maintain organized access to reference materials, policies, and procedures.

• Foster a professional, ethical, and member-centered work environment.

• Spot opportunities for workflow and system enhancements.

• Assist with system testing, coordinate case information within external vendor systems, or discuss service planning with providers.

⛳️ Requirements

• High school diploma or equivalent, along with 2 years of clinical or hospital experience, or a comparable combination of education and experience.

• LPN, CMA, or CNA credentials are preferred.

• Clinical experience, ideally within a hospital or health plan clinical services setting.

• Excellent oral and written communication abilities.

• Capability to thrive in a fast-paced environment while ensuring accuracy, confidentiality, and a customer-oriented approach.

• Intermediate computer proficiency, including Microsoft Office, Outlook, and online research skills.

• Familiarity with healthcare systems and documentation, including EMR, billing, and claims processes.

• Understanding of medical terminology, anatomy, and coding (CPT, DX, HCPCs).

• Strong organizational, data entry, and administrative capabilities.

• Skill in investigating and researching complex UM casework issues, utilizing critical thinking.

• Ability to work autonomously, prioritize tasks, meet deadlines, and fulfill operational standards.

• Proficient in collaborating effectively within a team environment.

• Capacity to perform UM Clinical Specialist duties and responsibilities.

• Ability to mentor colleagues and train new team members.

• Experience with AI tools and technologies is highly desirable.

• Personal mobile device is required for MFA.

• Wired internet connection is mandatory; satellite or cellular internet will not be accepted.

• Minimum internet upload speed of 5Mb and download speed of 10Mb is required.

• Background check is mandatory.

🏝️ Benefits

• 5% bonus target.

• Medical, dental, and vision coverage for employees and eligible family members, including mental health benefits.

• Annual employer contribution to a health savings account.

• Generous paid time off.

• 10 company-paid holidays.

• 401(k) company match.

• Potential discretionary retirement contribution based on company performance, with no vesting period.

• Up to 12 weeks of paid parental leave after 12 months of continuous service.

• Wellness programs that incentivize participation.

• Employee Assistance Fund.

• Commute and parking benefits.

• Work from home option available.

• Flexible work option requiring a wired internet service with minimum upload/download speeds.

• Company-supported outreach programs.

• Employee resource groups.

• Competitive base salary.