JOB SUMMARY

Responsible for providing customer service support for behavioral health benefits, directing members to appropriate in network services, processing prior authorizations according to CMS and State regulations, sending out provider faxes well as member letters, and resolving behavioral health related situations that arise from calls.

KEY RESPONSIBILITIES

Available and able to be telephone support from 8AM -5PM except for lunch and breaks to support behavioral health needs for all lines of business. Provides resolution for various types of phone calls including, but not limited to referral, authorization, and verifying member eligibility, line of business and network affiliations for members and providers. Determines if the call is clinical and requires transfer to a clinical staff person. Will inform callers, including members, facility personnel, physicians, or other health care professionals of the utilization requirements and procedures. Makes initial referrals that do not require evaluation or interpretation of clinical information to behavioral health services. Completes appropriate electronic certification and progress notes documentation of activities as needed. Assists with specialized job tasks which may include claims corrections and follow-up with provider/member questions regarding claims payments, generate provider faxes, generate member letters, and other administrative tasks. Work may also involve dealing with members who are disgruntled or upset. Performs other duties as required.

QUALIFICATIONS

Basic punctuation and grammar skills Ability to multi-task and manage time efficiently. Proficient in Microsoft applications. Ability to work independently and apply good judgment. Ability to maintain and preserve information of highly confidential nature. Possess strong oral communication skills. Successful completion of Health Care Sanctions background check.

EDUCATION/EXPERIENCE

High school diploma or equivalent. Customer service, office management, and/or healthcare experience preferred but not required. CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin