Clinical Support Specialist - CDPHP : Job Details

Grounded by a compelling mission, core values, and compassion for people, CDPHP and its family of companies offer a strong foundation for a rewarding career. Established in 1984, CDPHP is a physician-founded, member-focused, and community-based not-for-profit health plan that offers high-quality affordable health insurance to members throughout New York. The company values people, quality, innovation, and community, and its corporate culture supports those values wholeheartedly. CDPHP is committed to fostering a culture of belonging and takes a wholistic approach to diversity, equity, and inclusion. At CDPHP, the employees have a voice and are encouraged to make an impact at both the company and community levels through engagement and volunteer opportunities. CDPHP invests in employees who share these values and invites you to be a part of that experience.

The clinical support specialist (CSS) provides administrative support to clinical staff within Member Health. The CSS adheres to established customer service standards of accuracy, courtesy, and professionalism. This position supports timely determination turnaround times on all prior authorization requests and inpatient notifications received via telephone, fax, or mail. This position requires decision making to determine the appropriate action to take prior to logging and routing requests for authorization to the appropriate clinical reviewer. CSS reviews clinical documentation and determines at times what is being requested to allow efficient workflow. CSS reviews UM notification letters to ensure quality wording is chosen and aligns with the determination. This position must maintain a working knowledge and understanding of CDPHP benefit plans, contracts, provider networks, and Resource Coordination policies to maximize effectiveness. Answer provider and member inbound phone calls.

Qualifications:

+ A minimum of two (2) years experience in a health insurance related discipline required.

+ Utilization management experience is preferred.

+ Knowledge of managed care, health plan benefits, and be able to carefully assess medical information.

+ Perform work in a fast-paced environment with frequent changes.

+ Ability to multitask and work in multiple systems required.

+ Ability to review documents and use critical thinking.

+ Strong attention to detail required.

+ This position deals with reviewing medical information and creating Authorizations which include Diagnosis Codes, CPT codes, Medical terminology related to different types of Inpatient and Outpatient services.

+ Strong data entry skillset required.

+ Demonstrated customer service skills, and possess excellent listening, communication, and interpersonal skills.

+ Demonstrated ability to illicit required information; interact professionally with difficult callers, provider practitioners and members with ongoing assistance and education regarding plan requirements.

+ Ability to apply established criteria against documentation to identify and resolve issues is required.

+ PC experience in a Windows environment is required.

+ Ability to manage multiple tasks simultaneously and in an organized manner is required.

CDPHP salary ranges are designed to be competitive with room for professional and financial growth. Individual compensation is based on several factors unique to each candidate, such as work experience, qualifications, and skills. In addition to cash compensation, CDPHP employees may be eligible for an incentive payment, a discretionary cash reward based on employee and company performance. Some roles may also be eligible for overtime pay.

CDPHP compensation packages go far beyond just salary. The company offers a comprehensive total rewards package that includes award-winning health care coverage, health care dollars, a generous paid time off allowance, employee assistance programs, flexible work environment, and much more. Learn about all CDPHP employee benefits at .

As an Equal Opportunity / Affirmative Action Employer, CDPHP will not discriminate in its employment practices on the basis of race, color, creed, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship, disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, protected veterans status, or any other characteristics protected under applicable law. To that end, all qualified applicants will receive consideration for employment without regard to any such protected status.

CDPHP and its family of companies include subsidiaries Strategic Solutions Management Consultants (SSMC), Practice Support Services (PSS), and ConnectRx Services, LLC.