Description

California Hourly Rate Range: $27.29 - $38.21 per hour

Job Summary

A Clinical Support Associate III Lead (CSA III) is assigned to one of several Health Services clinical units. These units include Utilization Management, Case Management, Enhanced Care Management/Community Supports (Instead of Service), Care Coordination, Disease Management, Behavioral Health, and the Pediatric-Whole Child Model program. The CSA III Lead is responsible for providing coordination support for the clinical teams, supporting the daily operational functions, facilitating timely work processes, and performing clerical activities of the assigned unit. The CSA III Lead must have solid, transparent written and verbal communication skills. The CSA III Lead is responsible for accurate and timely data entry and collection. The CSA III Lead interacts with other CenCal Health employees, providers, and members. Depending on the unit assignment and overseen by the manager or their designee, a CSA III Lead may be responsible for processing authorization and referral requests, completing health surveys with members, and following selected members needing periodic telephonic outreach calls.

Duties and Responsibilities

The job duties and responsibilities vary in each unit. This position receives day-to-day supervision by the unit manager or their designee and includes, but is not limited to, the following tasks for the specified unit:

General CSA III Lead Duties and Responsibilities:

• Timely communication of conflicts or difficulties with members or providers to the immediate supervisor

• Timely answering of inbound calls in the Health Services’ phone queues

• Make outbound calls to providers, members, and CenCal Health staff regarding operational processes.

• Maintain confidentiality and privacy of member information in adherence to HIPAA and Confidentiality laws and regulations.

• Adhere to CenCal Health’s mission, protocols, policies, and procedures and meet required performance standards.

• Timely attendance of Company-wide and department meetings and training and, as appropriate, actively participate.

• Respond to emails, telephone calls, and other modes of communication promptly, professionally, and courteously.

• Interact with CenCal Health employees, members, and providers professionally.

• Other duties as assigned.

The CSA III Lead will be assigned to a core unit (UM, CM, CC, DM, ECM, CS, BH, or Pediatric) and need to demonstrate proficiency in the general and unit-specific Duties and Responsibilities of the core unit.In addition, the CSA III Lead will need to demonstrate ongoing ability to perform the essential duties of the other Health Services units and be willing to perform such duties as required.

When assigned to Utilization Management:

• Answer inbound calls from the unit phone queue and make outbound calls to providers and members regarding authorization request status.

• Accurately enter authorization requests and submitted documents into the authorization system.

• Obtain all necessary documentation required to process referrals and requests for covered services.

• Respond to inquiries regarding the authorization processes and request statuses from providers, members, and staff from other departments.

• Act as a liaison between clinical reviewers and providers/members.

• Accurately enter billing and diagnosis codes, category and type of service, amount, frequency, and volume of requested or approved services and procedures.

• Process authorization requests within established timeliness standards.

• Track and monitor the timeliness of service authorization and referral requests.

• Accurately prepare, edit, and finalize written determination notices to providers and members.

• Prepare timely and accurately formatted notices and retain/store documents related to authorization requests and determination notices.

• Verify eligibility and other payor source.

• Collaborate and communicate with other Health Plan departments such as, but not limited to, Member Services, Providers Services, and Claims.

• Inform members and providers of the authorization and appeal processes.

• Adhere to authorization timelines of Federal and State agencies that govern health plan operations.

• As directed, process long-term care recertification.

• As directed, process inpatient authorization requests.

• Process limited authorization requests according to written guidelines.

When assigned to Case Management, Care Coordination, or Disease Management:

• Work closely with the clinical team, which includes physicians, nurses, and social workers.

• Make phone contact with members.

• As assigned, telephonically screen the member’s well-being and contact their family or authorized representative.

• As the clinician assigns, perform tasks identified in a member-centered care plan to meet or progress toward established goals or outcomes.

• Follow members in the lowest level of case management or care coordination services as assigned.

• Promptly communicate any changes in a member's status to the assigned clinician.

• Organize, schedule, track, and monitor member contacts.

• Submit accurate reports and complete documentation promptly.

• Perform timely outreach calls to members.

• Assist members with completing health surveys.

• Generate and mail post-program satisfaction surveys and, as necessary, perform outreach calls.

• Adhere to department protocols and procedures for electronic data entry and form completion.

• As requested, participate in the case conference and care plan development

• Provide members with community and referral resources that may benefit their ability to self-manage their condition and maintain their independence.

• Work collaboratively with the clinical team to monitor the member’s adherence to their established care plan.

• Act as an advocate for the member, recognizing the member’s values.

When assigned to Enhanced Care Management or Community Supports:

• Responsible for supporting the daily operational functions, facilitating timely work processes, and performing clerical activities associated with ECM/CS

• Work closely with CM, the ECM/CS team, and internal CenCal Departments related to ECM/CS activities.

• Managing the call queue, including supporting members, ECM/CS providers, and providers related to ECM/CS referrals and provider reassignment process.

• Responsible for the ECM/CS referral intake process and ECM provider assignment.

• Conduct follow-up calls to members and providers to ensure timely ECM/CS services access.

• Organize, schedule, track, and monitor member contacts.

• Assist with mailings associated with ECM/CS (Member assignment and Auth approval notifications)

• Assist with mailings of ECM/CS NOA’s as requested.

• Assist the ECM/CS Program Manager with data tracking as requested.

When assigned to the Pediatric-Whole Child Model Program or Behavioral Health Treatment Team:

• Dual-role position: Performs general CSA duties and theresponsibilities and tasks outlined for CSA assigned to theUtilization ManagementandCase Management/Care Coordination/Disease Managementprograms.

Qualifications

Knowledge/Skills/Abilities

Required:

• Demonstrate ongoing ability to perform the essential duties of another non-core Health Services unit.

• Ability to work independently and follow directions with minimal supervision and as an active participant in an interdisciplinary team.

• Ability to utilize constructive criticism as a learning and growth opportunity.

• Demonstrate excellent organizational and multi-tasking skills.

• Understand basic medical terminology, billing (CPT), and diagnoses (ICD-10) coding.

• Maintain member confidentiality and HIPAA compliance.

• Must be detail-oriented and maintain clear and accurate records.

• Complete assigned duties while adhering to regulatory timelines.

• Must be able to learn and utilize multiple electronic platforms and database systems.

• Work effectively with people with varying backgrounds and educational levels.

• Prepare grammatically correct, clear, and concise correspondence.

Preferred:

• Basic knowledge of Medi-Cal and its covered services

• Knowledge of health-related community-based organizations, healthcare delivery systems, and resources for the low-income and elderly population

• As designated, bilingual in Spanish (not required for Utilization Management positions)

Education and Experience

Required:

• High school diploma or GED

• An associate degree in health science, healthcare, health management, or a related field OR five (5) years of experience as a Certified Medical Assistant, Certified Nursing Assistant, or Licensed Vocational/Practical Nurse may substitute for an associate degree.

• In good standing with no performance disciplinary actions

• Two (2) years of full-time, or its equivalent, experience at a health planormanaged care organizationinMedical Management (e.g., Utilization Management, Case Management, Disease Management)orMember Services department, which required working directly with patients, members, providers, and other clinicians.

• One (1) year of full-time or its equivalent experience in a lead or higher-level positionora clinical support position with progressive work responsibilities at a Medi-Cal managed care or other managed care organization’s medical management department (utilization or case management) OR one year experience at CenCal Health’s Health Services Department in a clinical support position.

Preferred:

• Bachelor’s degree in one of the above fields