Previous Job
Clinical Operations Support Specialist-LJ
Ref No.: 17-10015
Location: Glen Allen, Virginia
Start Date / End Date: 07/25/2017 to 12/29/2017

Key details:
This position is in a call center environment. Ensure that the candidate is aware of this and is comfortable with this. A lot of candidates that have interviewed were not aware of this and it was a deal breaker.

When the candidate is not on the phone they will be multi-tasking on other administrative functions. They will be performimg authorizations, processing claims. This is for the Medicaid/Medicare population. Prior knowledge of working with Medicaid and Medicare would be very beneficial.


Actual JD:

Humana has an exciting opportunity to join the Clinical Operations Support Team supporting the Virginia Duals. This role affords an opportunity to be a part of the clinical space, providing support to our clinical coordinators and providers to ensure that our members are connected with needed services to promote their highest level of wellness and independence.
Individuals in this role will be expected to perform the following functions for our Long Term Services and Support (LTSS) population:
• Fielding Virginia specific telephonic inquiries
• Entering of LTSS authorizations to ensure continuity of care for newly enrolled members
• Provider outreach to ensure they have the ability to meet the members needs
• Approval of authorizations based on predetermined criteria
• Member outreach to ensure that providers have begun providing services and that there are no gaps in service
• Troubleshoot authorization concerns from providers, provider representatives or care coordinators (CC)
• Researching issues from Public Partnerships, LLC (PPL) for consumer directed enrollees
• Research pended claims in MACESS to assess and correct authorizations, if needed, to resolved the claim
• Compilation of transition authorizations from the CGX system as well as multiple partners for members leaving Humana
• Compile and/or review reports for internal and external use
• Collaborating with CC to ensure member needs are met
• Over sight of expiring authorizations and communication with CC to ensure there are no gaps in member care
• Receiving communications form Personal Emergency Response System (PERS) providers and alerting assigned CC for member follow-up
• Receiving and processing of faxes to ensure appropriate disposition
• Creating and mailing communications to members and providers
• Review of various reports to determine when action should be taken
• Research and validation that enrollees are enrolled in the correct enrollment classification
• Other duties deemed necessary for effective and efficient team operations
• Additional populations that may be added as a result of changes in the upcoming MLTSS program include the following:

Additional populations that may be added as a result of changes in the upcoming MLTSS program include the following:
? Community Well Duals (CW)
? Intellectual Disabled (ID)
? Developmentally Disabled (DD)
? Day Supports (DS)
? Technology Waiver (TW)
? Aged Blind and Disabled (ABD)

Key Competencies
• Accountability: Meets established expectations and takes responsibility for achieving results and encourages others to do the same
• Builds Trust: Consistently models and inspires high levels of integrity, lives up to commitments, and takes responsibility for the impact of one's actions
• Collaborates: Engages others by gathering multiple views and being open to diverse perspectives focusing on a shared purpose that puts our member's first
• Customer Focus: Connects meaningfully with internal and external customers to build emotional engagement and customer advocacy. Simplifies complexity and integrates internal efforts to deliver an optimal customer experience.
Role Essentials
• High School Diploma
• 2 years' experience demonstrating superior working knowledge of computers with demonstrated technical aptitude and ability to quickly learn new systems as well as working in multiple systems or programs at the same time
• Proficiency in all Microsoft Office applications, especially Excel
• Demonstrated familiarity with medical terminology and/or ICD-10 codes
• Possess a strong attention to detail, sound critical thinking and follow up skills
• Ability to manage multiple priorities simultaneously; and work within contractual timelines and short turn-around times
• Ability to evaluate data, use appropriate problem solving, research and analysis tools
• Demonstrated ability for adapting to a constantly changing workload or unforeseen situations
• Excellent communication skills, both verbal and written
• Excellent customer service skills
• Demonstrated ability to function independently and responsibly with minimal need for supervision
• The ability to thrive in a fast paced environment
Role Desirables
• Associate's or Bachelor's Degree
• Prior experience with Duals or Medicaid Products
• Prior experience with Customer Care Centers, Humana CGX and/or MACESS systems