Clinical Services Representative II

About The Company

PEHP Health & Benefits is a division of the Utah Retirement Systems that proudly serves Utah’s public employees through high quality and competitively priced medical, dental, life, and long-term disability insurance plans on a self-funded basis. As a government entity, we embrace both a public mission and a commitment to creating customer value, excelling in the market, and improving healthcare. We offer a competitive salary with generous benefits, personal development in a positive team environment, and excellent work-life balance.

For most jobs, remote work is available for 9 out of every 10 workdays.

Job Description

POSITION SUMMARY

This position supports PEHP’s efforts to mitigate the rising cost of health care and provide excellent customer service. This position performs a variety of support duties including clinical services technical support, customer service support, and education through inbound and outbound communications. This position also collaborates with PEHP nurses, pharmacists, and doctors; provides customer service to PEHP members and network physicians; solves problems with pre-authorizations or claims and assists the Clinical Management department in pre-authorization evaluation and the disputed/appealed pre-authorization process. The successful candidate will have excellent communication skills, a basic understanding of medical terminology, understand medical claims payments, the ability to learn and apply new information, and is willing to go the extra mile to provide excellent customer service. The incumbent must always demonstrate good judgment, high integrity, and personal values consistent with the values of URS.

ESSENTIAL JOB FUNCTIONS AND DUTIES

Required Experience

Education and Experience

High School diploma and three (3) years of progressively responsible experience in a medical setting (insurance, practice, facility, etc.), or an equivalent combination of education and experience.

Certification as a Nursing Assistant (CNA), Medical Assistant (AAMA), Current Procedural Terminology (CPT), registered pharmacy technician (CPhT), or other health care related license/certificate is preferred.

Certified Professional Coder (CPC) or medical terminology certification and or specific experience in claims processing, computer software applications, and electronic billing procedures is preferred.

Knowledge, Skills, and Abilities

This list contains knowledge, skills, and abilities that are typically associated with the job. It is not all-inclusive and may vary from position to position:

Required technical skills include the working knowledge and ability of:

• Various office management systems related to alpha and numeric record keeping.
• Healthcare Information Systems.
• Pharmacy software programs.
• Electronic billing procedures.
• Personal computer operations.
• Microsoft Office Suite.
• 10-key.

Required working knowledge of:

• Medical, dental, pharmaceutical and Medicare Supplement claims adjudication policies, procedures, and processes.
• Intricacies related to medical, dental, pharmaceutical, and mental health claims.
• Claims review processes and procedures.
• Healthcare coding.
• Enrollment processes.
• Basic medical terminology.
• Pharmacy adjudication policies.
• Intricacies related to drug usage, dosage, definitions, and codes.

Must possess excellent communication skills:

• Telephone etiquette.
• Public relations skills.
• Communicate effectively verbally and in writing.
• Establish and maintain effective working relationships with professionals, executives, department heads, coworkers, and the public.
• Analyze a variety of escalated issues and problems and make recommendations directly related to pharmacy claim functions.

Must have the ability to:

• Multi-task by handling a variety of duties in a timely and efficient manner.
• Draft technical reports, documents, manuals, and instructions.
• Document information accurately and succinctly.
• Apply intermediate mathematics related to the metric system to calculate drug dosages as related to pharmacy/medical claims.
• Maintain effective working relationships with professionals, department heads, co-workers, and the public.
• Follow written and verbal instructions.
• Follow a well-organized work routine.
• Work well in a team environment as well as independently .
• Deal effectively with stress caused by workload and time deadlines and handling difficult or irate phone calls.
• Prioritize work.
• Perform within deadlines.
• Follow through with assignments.

The incumbent must always demonstrate judgment, high integrity, and personal values consistent with the values of URS.

Work Environment

Incumbent performs in a typical office setting with appropriate climate controls. Tasks require a variety of physical activities which do not generally involve muscular strain, but do require activities related to walking, standing, stooping, sitting, reaching, talking, hearing, and seeing. Common eye, hand, finger dexterity required to perform essential functions.