Summary: The Clinical Support Specialist (CSS) is a valuable member of the clinical support team that is collectively responsible for servicing all aspects of the prior authorization process, the tracking and maintenance of the medical records under all HIPAA rules, and coordinating referrals as directed by CHP clinicians on a patient’s behalf. The clinical support team serves each CHP site equally. Manages relationship between patient and health center, with various insurance companies, to ensure compliance with referral and authorization requirements. S/he is responsible for monitoring physical and electronic faxes and incoming documentation, including various items found in the Athena Clinical Inbox (“buckets”). The CSS will support CHP’s mission, vision, and values, and will adhere to compliance protocols as well as CHP’s policies and procedures.
Clinical Support Specialist Essential Duties and Responsibilities:
- Files all medical information either by scanning or bar coding into patient charts in timely manner.
- Responds to requests for files from providers.
- Sends/receives files from other providers as requested, always following HIPAA protocols.
- Performs clerical duties as requested pertaining to medical record releases.
- Documenting fax and invoice status of records in Athena.
- Barcode and scan documents into Athena.
- Generate invoices and track payments for records.
- Efficiently obtain all authorizations for procedures to be performed, prior to patients scheduled date of service.
- Notify scheduling staff of delays in obtaining required authorizations.
- Inform supervisor about any changes or patterns they are seeing in denials of procedures.
- Accept, handle, and process incoming patient telephone inquiries using appropriate customer service skills, clarify and validate patient inquiries, questions or complaints and correct and update patient account information in the computer system.
- Coordinates all outgoing/incoming referrals:
- Maintains the computerized managed care system log and maintains electronic referrals in EMR.
- Schedules all referral appointments and documents this information on the referral request form and practice management system, and notifies patient of same.
- Collaborates with the primary care provider to resolve issues related to specialist availability and patient needs.
- Files all completed referral forms in the patient’s chart.
- Maintains a system for easy access to authorization numbers, number of visits, and utilization.
- Completes follow-up with hospitals with regard to submitting orders and any other related documentation (financial or clinical).
- Functions as a resource of information and problem solving for patients, primary care providers, managed care program staff, specialists and health center staff.
- Maintains up-to-date knowledge of insurance company requirements, communicating changes to colleagues and peers.
- Assists with development and presentation of managed care reporting on monthly basis, including but not limited to: indicating numbers of referrals, turnaround time for booking referrals and utilization.
- Attends appropriate meetings to maintain up to date knowledge of team and CHP activities.
- If unable to attend meetings, contacts supervisor for information.
- Attends appropriate various external organizational meetings with insurance companies and hospitals.
- Maintains documentation to meet audit requirements and participates in audit activities as requested.
- Attendance/Punctuality - is consistently at work and on time.
- Ensures work responsibilities are covered when absent.
- Handle and process incoming patient correspondence.
- Participates in HRSA activities as needed.
- Provide clear explanations of appropriate patient-related policies.
- Maintains patient confidentiality in accordance with established policies.
- All other duties as assigned.
Competencies: To perform the job successfully, an individual should demonstrate the following competencies:
- Strong ability to multi-task
- Maintains patient confidentiality
- Professional demeanor and appearance
- Strong time management & prioritization skills
- Customer service - manages difficult or emotional customer situations
- Responds promptly to customer needs.
- Solicits customer feedback to improve service.
- Responds to requests for service and assistance.
- Meets commitments and is punctual.
- Follows policies and procedures.
- Completes administrative tasks correctly and on time.
- Supports organization's goals and values.
- Flexible and willing to cover whichever tasks are most urgent based on changes in workload and staffing.
- Clear communication amongst team to facilitate patient needs and care.