Job Category: Healthcare Services and OperationsJob Description:Your RoleThe Specialty Services team is a branch off the MCS Intake team. The Clinical Support Coordinator, Advanced will report to the Specialty Intake Manager. In this role you will be required to process phone and faxed requests for Continuity of Care, Access to Care for both commercial and Medi-Cal membership. This role may also require Peer or Peer provider support and other duties within Medical Care Solutions.Responsibilities:Your WorkIn this role, you will:
Process faxed/phoned in authorizations, UM/CM requests, special processing/case types and/or calls left on voicemail
Monitor specific queues/workstreams and generates pre-defined reports to identify and resolve common errors
Handle customer/provider problematic calls
Check member history for case management triage and research member eligibility/benefits and provider networks
Assign initial EOA days, or triage to nurses, based on established workflow
Assist with audit file prep
Collaborate with team members on difficult cases for best practices
Promote and maintain and ensure a safe, secure, and healthy work environment by following standards and procedures and complying with company policy
Assist our Clinical staff with case questions, research, and special requests
Cross train in other MCS process as needed
Qualifications:Your Knowledge and ExperienceRequires a high school diploma or equivalentRequires at least 5 years of prior relevant experienceRequires flexibility and insightfulness * Requires the ability to work independently using documented processes
Requires the ability to make decisions quickly, effectively, and without doubt
Previous MCS Intake experience preferred but not required
3 years of work experience within the Medical Care Solutions' Utilization Management Department or a similar medical management department at a different payor, facility, or provider/group preferred. Experience with Medicare and/or Medi-Cal is preferred.
In-depth working knowledge of the prior authorization review and non-clinical business rules and guidelines, preferably within the Pre-service area.
In-depth working knowledge of the systems/tools utilized in the UM authorization functions such as AuthAccel, Facets, AEVS and PA Matrix or other systems at a different payor, facility, or provider/group preferred.
Ability to work in a high-paced production environment with occasional overtime needed (including weekends) to ensure regulatory turnaround standards are met.
Knowledge of UM regulatory TAT standards
Knowledge of clinical workflow to assist nurses with case creation, research/issue resolution and other UM related functions, as necessary.
About the Team:About Blue Shield of CaliforniaAs of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities - join us!Our Values:
Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.
Our Workplace Model:At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose - whether working in the office or through a hybrid approach - by providing clear expectations while respecting the diverse needs of our workforce.Two Ways of Working:
Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above). Exceptions:
o Member-facing and approved out-of-state roles remain remote.o Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.o For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.
On-Site: Work from a business unit-approved office an average of four (4) or more days a week.
Physical Requirements:Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.Equal Employment Opportunity:External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.
