Clinical Support Specialist

Remote Jobs; Harrisburg (Dauphin County); On-site; USD 42,000 - 54,000; Full time

Job summary

Capital Blue Cross is seeking a Clinical Support Specialist to provide administrative support to the clinical team, handling medical management records, authorizations, and referral management. The role emphasizes accuracy, regulatory compliance, and effective communication with members and providers.

You will support UM, CM, and PHM processes, participate in reporting, and help maintain high standards of service within a collaborative team environment. Experience in medical field preferred.

Qualifications

• Minimum 2 years' experience in the medical field or 2 years in a managed care clinical department.
• Proficiency with Microsoft Office and medical terminology.
• Knowledge of health insurance industry and plan products (e.g., PPO, HMO).
• Familiarity with NCQA and CMS regulatory standards.

Responsibilities

• Support clinical processes by building medical management records and authorizations.
• Conduct outreach to members/providers to communicate UM/CM status.
• Assist with administrative functions at health events such as health fairs.
• Document interventions in the member's medical management record per policies.
• Support department compliance and performance via report monitoring and distribution.

Skills

Strong organizational and time mgmt

Attention to detail

Policy and procedure compliance

Written and oral communication

Education

High School Diploma

Continued higher education

Job description

Position Description

Base pay is influenced by several factors including a candidate's qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more.

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it's why our employees consistently vote us one of the "Best Places to Work in PA".

Provides administrative support to assigned clinical team, as directed by the Team Lead and/or Manager. The Clinical Support Specialist will perform administrative tasks that support clinical processes (e.g. UM, CM, PHM), including but not limited to building medical management records (e.g. authorizations and referral management), compliance report monitoring, and completion of member/provider communications.

Responsibilities and Qualifications

• Assists with medical record documentation requests and leverages medical management system to initiate case and/or authorization to support clinical processes (e.g. UM, CM).
• Conducts fax and telephonic outreach; and written communications to members and/or providers to communicate status of UM/CM processes (e.g. verbal notification, engagement status, discharge plan).
• Supports administrative functions with community events (e.g. health fairs)
• Accurately documents all interventions in the member's medical management record in accordance with established policies and procedures.
• Actively participates in supporting department compliance and performance through administrative activities such as report monitoring/distribution, and other tasks as assigned by leadership.
• Adheres to all regulatory and compliance standards, including adherence to all Capital and department specific policies and procedures.
• Interacts courteously and professionally with customers, including internal staff, vendor partners, providers, and members to support collaborative medical management functions.
• Identifies and reports potential quality of service/care issues as established and within the guidelines of intradepartmental processes.
• Promotes personal growth through participation in staff meetings, appropriate in-services, and corporate training.
• Identifies opportunities and proposes alternatives for improving the Population Management functions.

Skills

• Strong organizational and time management skills.
• Demonstrated strong attention to detail and accuracy.
• Ability to follow job responsibilities as outlined in departmental policies and procedures.
• Excellent written and oral communication skills.

Knowledge

• Working knowledge and operation of a personal computer, including proficiency in Microsoft Office applications.
• Working knowledge of medical terminology.
• Working knowledge of the health insurance industry, health plan benefits and product lines (e.g., PPO, POS, HMO, FEP, Senior Products, Traditional/Comprehensive).
• Knowledge of regulatory and accreditation standards and requirements (e.g. NCQA, CMS).

Experience

• Minimum 2 years' experience in the medical field (e.g. medical assistant, medical secretary) or 2 years' experience in a managed care clinical department.

Education and Certifications

• High School Diploma required.
• Continued higher education preferred.

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career. And by doing your best, you'll help us live our mission of improving the health and well-being of our members and the communities in which they live.