Care Management Specialist II

Premera Blue Cross; Washington; Hybrid; USD 48,000 - 73,000; Full time

Job summary

Premera is hiring a Care Management Specialist II to independently handle intake for inpatient and outpatient service requests across multiple lines of business.

You will use Facets, Jiva, and Appian to process inquiries, triage with clinical staff, and ensure compliance with regulatory standards.

Qualifications

• High School Diploma or GED (Required).
• One (1) year of experience in a customer service-oriented environment (Required).
• Prior Health Plan experience (Strongly Preferred).
• Associate degree in medically related field (Preferred).
• One (1) year of experience with Premera systems and tools (Preferred).
• Demonstrated effective written and verbal skills with the ability to communicate professionally.
• Demonstrated effective telephone skills.
• Effective time management, organization and prioritization skills.
• Demonstrated ability to handle stressful situations, work in a high production environment and follow through on assigned tasks.
• Ability to work independently and as a member of a team and to work flexible hours to meet specific work demands.
• Intermediate skills with Microsoft Office Outlook, Word, Office Communicator, Live Meeting; familiarity with Excel.
• Basic knowledge of medical terminology.

Responsibilities

• Applies knowledge of Facets, Jiva, and Appian to manage inpatient and outpatient service requests.
• Triage and consult with clinical staff as appropriate for medical inquiries.
• Process and load incoming information for inpatient notifications, discharges, pre-service requests, and outpatient services.
• Apply regulatory and accreditation standards related to the role.
• Follow scripted clinical criteria and collect data for initial case screening.
• Handle specialized account needs and complex inpatient/outpatient requests.
• Identify system/provider issues and propose process improvements.
• Assist in training and supporting new team members.

Skills

Customer service

Verbal communication

Written communication

Time management

Teamwork

Education

High School Diploma or GED

Associate degree in medically related field

Tools

Facets

Jiva

Appian

Excel

Outlook

Word

Office Communicator

Live Meeting

Job description

About the position of the Care Management Specialist II

The Care Management Specialist II works independently performing intake of inpatient and outpatient service requests and provides information to external customers and medical professionals as related to medical services inquiries. This Specialist is responsible for managing all lines of business. In this role you will work independently and apply your understanding of a variety of complex lines of business (e.g. national accounts, self-insured, fully-insured) when responding to both providers and facilities regarding their clinical review questions and requests. The Care Management Specialist II requires a permanent weekend schedule. The employee hired into this role will be scheduled to work both Saturdays and Sundays on a regular, ongoing basis with the ability to request PTO subject to availability. Candidates should apply only if they are able to commit to working both weekend days as part of their permanent schedule. This schedule would start after the training and ramp-up period.

What you’ll do:

• Applies knowledge of various applications within the Facets claims payment system and the Jiva Healthcare Management Platform (e.g. customer service, benefits, eligibility, prospective UM) in order to manage incoming inpatient and outpatient service requests via fax and electronic submission.
• Serves as a resource for the customer service representatives for medical inquiries that cannot be resolved by Operations; triages and consults with clinical staff as appropriate.
• Utilizes various applications (e.g. Facets, Jiva, and Appian) to process and load incoming information for inpatient notifications, discharges, pre-service requests, and outpatient services.
• Applies understanding of regulatory and accreditation standards related to the role.
• Follows clinical criteria as scripted, utilizing knowledge of medical terminology to collect data, conduct initial case screening and process requests.
• Review and collection of data does not require any clinical evaluation or clinical interpretation of information.
• Handles specialized account needs, and complex inpatient and outpatient account specific needs (e.g. customized benefit requests, overlapping coverage issues, special benefit handling).
• Identifies system and provider issues and trends; recommends changes to processes and takes lead in initiating improvements (e.g. team meeting discussions, creates job aides, initiation of procedure changes).
• Assists in training and supporting new team members

What you’ll bring:

• High School Diploma or GED (Required).
• One (1) year of experience in a customer service-oriented environment (Required).
• Prior Health Plan experience. (Strongly Preferred).
• Associate degree in medically related field (Preferred).
• One (1) year of experience with Premera systems and tools (Preferred).
• Demonstrated effective written and verbal skills with the ability to communicate professionally.
• Demonstrated effective telephone skills.
• Effective time management, organization and prioritization skills.
• Demonstrated ability to handle stressful situations, work in a high production environment and follow through on assigned tasks.
• Ability to work independently and as a member of a team and to work flexible hours to meet specific work demands.
• Intermediate skills with Microsoft Office Outlook, Word, Office Communicator, Live Meeting; familiarity with Excel.
• Basic knowledge of medical terminology.

Premera total rewards

• Medical, vision, and dental coverage with low employee premiums.
• Voluntary benefit offerings, including pet insurance for paw parents.
• Life and disability insurance.
• Retirement programs, including a 401K employer match and, believe it or not, a pension plan that is vested after 3 years of service.
• Wellness incentives with a wide range of mental well-being resources for you and your dependents, including counseling services, stress management programs, and mindfulness programs, just to name a few.
• Generous paid time off to reenergize.
• Tuition assistance for both undergraduate and graduate degrees.
• Employee recognition program to celebrate anniversaries, team accomplishments, and more.
• Commuter perks make your trip to work less impactful on the environment and your wallet.
• Free convenient on-site parking.
• Subsidized on-campus cafes make lunchtime connections with colleagues fun and affordable.
• Participate in engaging on-site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more.
• Complementary fitness & well-being center offers both in-person and virtual workouts and nutritional counseling.
• Game of shuffleboard or ping pong while on campus.

Equal employment opportunity/affirmative action:

Premera is an equal opportunity/affirmative action employer. Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law. If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at [e-mail] or via phone at 425-918-4785.

Premera is hiring in the following states, with some limitations based on role or city:

Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, Wisconsin.

The pay for this role will vary based on a range of factors including, but not limited to, a candidate’s geographic location, market conditions, and specific skills and experience.

National Salary Range: $48,400.00 - $72,600.00

National Plus Salary Range: $55,200.00 - $82,800.00 *National Plus salary range is used in higher cost of labor markets including Western Washington and Alaska.

We’re happy to discuss compensation further during the interview because we believe that open communication leads to better outcomes for all.

We’re committed to creating an environment where all employees are celebrated for their unique skills and contributions. At Premera, we make healthcare work better. By focusing on improving our customers’ experience purposefully and serving their needs passionately, we make the process easier, less costly, and more positive. Through empathy and advocacy, we change lives. As the leading health plan in the Pacific Northwest, we provide comprehensive health benefits and services to more than 2 million customers, from individuals to Fortune 100 companies. Our services include innovative programs focused on health management, wellness, prevention, and patient safety. We deliver these programs through health, life, vision, dental, disability, and other related products and services. Premera Blue Cross is headquartered in Mountlake Terrace, WA, with operations in Spokane and Anchorage. The company has operated in Washington since 1933 and in Alaska since 1952. With more than 80 years of experience in the region, we deliver innovation, choice, and expertise.