Clinical Services Liaison
We specialize in managing independent groups of physicians with both commercial and senior managed care (HMO) patients. Our company is built on more than 100 years of collective experience in the managed care (healthcare) industry providing personalized care and exceptional service. We’re conveniently located in North County San Diego bordering Oceanside and Vista.
Our Clinical Services team supports the health care services for all of our IPAs. If you are skilled, confident and adaptable, we have an excellent opportunity for a full-time Clinical Services Liaison who will actively participate in the patient referral process to insure quality and professional service to our referring physicians and members.
We seek the following qualifications:
- The ability to read, write and speak English and perform other basic educational skills as is generally obtained by successfully completing High school or a GED equivalent.
- Clear and accurate knowledge of medical terminology; managed care experience and knowledge preferred.
- At least one year of experience in Medi-Cal managed care authorization processes.
- Knowledge of Medi-Cal and CCS programs, preferred but not required.
- Working knowledge & expertise of ICD-10 & CPT codes.
- Demonstrated computer literacy. Excel experience helpful.
- Excellent communication skills in both oral and written modes, as well as superior telephone etiquette.
- Excellent Customer Services experience and proficiency required.
- English and Spanish/Vietnamese speaking preferred
Key Responsibilities Include (* = essential functions):
- To verify eligibility & benefits for each submitted physician referral by contacting the Health Plans for pertinent information.*
- To process and complete authorization request forms into the company’s in-house system in a consistently accurate and timely manner, as well as referring the authorization request forms to the appropriate staff members for processing.*
- To input referrals at or above the bench-mark processing daily quota.*
- To communicate in a timely manner, the authorization request form disposition back to the appropriate staff, physicians, and facilities per NCQA and Health Plan guidelines.*
- To organize & act upon pended, denial files/cases in a timely manner to maintain designated turnaround times and physician communication.*
- To answer telephone calls coming into the UM Department in a timely, courteous & professional manner.
- To collaborate with the CM to ensure all members are assisted with the coordination of care.
- Integrate behavioral health in collaboration with the PCP and CM when indicated
- Identify and refer members into ACM when indicated
- Ensure all specialty notes are shared with the CM and the PCP
- Help to coordinate transportation for members
- Refer members to community based resources when appropriate
- Assist the CM in all aspects of ACM within the scope of job responsibilities
- To maintain the transition log for special needs plan (SNP) members
- To assist the case manager to prepare for SNP audits
- To maintain a tracking system for health risk assessment (HRA) and care plan (ICP) completion dates
- To submit the requested SNP reports in a timely manner to the health plans
- To work with contracting personnel to insure utilization of appropriate providers.
- To provide requested referral and network information to providers/staff in a timely manner.*
- To provide information to licensed nursing staff regarding referrals that are “not a covered benefit” and facilitate denial letters.
- To organize, manage and prioritize workload effectively with the goal of processing authorization request forms within the established time frame.*
- To refer appropriate authorization request forms to IPA case manager based on established criteria.
- To educate and inform physicians and their office staff of any changes to referral process, network changes or other information pertaining to the referral process.
- To maintain daily, weekly or monthly reports as requested by IPA Administrator.
- To assist case manager and IPA Administrator in preparation of UM and QI meetings.
- To perform other duties as assigned.
- To maintain a courteous and professional demeanor in all interactions, with all persons both inside and outside the office.
At Physicians DataTrust you’ll enjoy a rewarding career with our growing company and progressive, friendly work environment while receiving a generous portfolio of benefits including medical, dental, vision, life insurance, 401k with company match, (FSA) Healthcare Flexible Spending Account, paid sick time, holidays and vacation. Compensation for this position is dependent upon experience.
For consideration please submit your cover letter and resume. Please indicate Clinical Services Liaison in the subject line.
~Physicians DataTrust is an (EOE) Equal Opportunity Employer~
Job Type: Full-time
- Medi-Cal Managed Care authorization processes: 1 year (Required)
- Clinical Liaison: 1 year (Preferred)