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Wixom, MI

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nnJob DescriptionnGeneral Summary The Clinical Support Specialist II is the front line interface to members and providers who seek information about behavioral health benefits. Assist callers by providing benefit and eligibility information and referrals to network providers. Assist with Clinical Department operations Conduct referrals, follow-up protocols, investigation of complex member/provider issues not requiring a medical necessity determination, claims issues and managing data to ensure patient and provider continuity of services. Provide guidance and handle complicated inquiries related to case initiation to internal and external customers. Educate providers/subscribers in the certification process and help to reconcile inconsistencies and procedural difficulties. rn Duties and Responsibilities Interface with medical carriers, claims payers, other. Initiates and maintains positive and productive relationships with external and internal customers. Handles difficult customer service problems and expedites resolution. Assist department/unit with call management. Interface with external and internal customers to ensure optimal efficiency of accessing behavioral health services. Provide education to providers and members on all aspects of care management services. Perform review of service request for completeness of information. rn (Kaiser Unit): Verifies member benefits and eligibility through health plan computer access, phone, and e-mail. Educates callers about Beacon/BCBHM services and their mental health benefits. Obtains urgent, routine with assistance appointments within established time frame guidelines. Checks voice mail and return calls within 1 business day. Checks e-mail to stay informed of procedures and communicate with team members. Works with health plan, County entities, community agencies and providers to effectively coordinates member care. Provides resources and referrals to members. Identifies calls requiring clinical evaluation or interpretation and refer to licensed clinician. Verify benefits against contract requirements prior to case initiation. Refer complicated inquires to Care Managers. Complete transactions/authorizations. Prepare account specific cases for Care Manager follow-up. Process account specific outpatient authorizations. Assist with triage assessment and referral process. rn Perform follow-up services for cases that may include CDR/EAP involvement & associated tasks, ambulatory follow-up procedures, depression management, medical/behavioral coordination and intensive care management protocols. Screen psychological testing requests for Care Manager follow up. Assist with specialty/distance waivers by completing rate negotiations and appropriate paperwork. Assist Care Managers in gathering data and making appropriate referrals to providers. Search for specialty providers or referrals in areas with difficult access and may respond to complicated inquiries. May participate in the investigation and resolution of claims and/or case issues. Oversee and support work process for clerical support staff. Collect and transfer non-clinical data. Acquire structured clinical data. Perform activities that do not require evaluation or interpretation of clinical data. Obtain and enter discharge information. Participate in periodic systems testing. Administer, track and record complaints, appeals, out of network authorizations including research and referrals in difficult access areas. Process appeal/denial issues. Investigate and resolve customer issues/complaints. Prepare and send out appeal letters per appeal policies. rn Perform responsibilities in accordance with contract standards. Provide training, as needed based on department needs. Assist service center with compliance of regulatory standards. Initiate and maintain all databases and records used by the Department. Enter data, update and/or correct information, run queries and reports. Prepare symposium reports. Perform administrative and clerical duties as needed, to support the business and service needs of the Department. Create and generate documents, reports, tables and graphs from raw data. Enter and update information, run reports and interpret data from the system as necessary. rn Apply Beacon Health Options policies and procedures consistently. Maintain confidentiality of Clients, Business Records and Reports. Maintain ethical and professional standards. Maintain individual productivity and performance standards. Meet Departmental expectations; accuracy, productivity and performance standards. Support Beacon Health Options in achieving Mission Statement. Adhere to the components of the Compliance Program. Ensure that job tasks are performed in a legal and ethical manner. Actively assess work area for non-compliance issues and notify supervisor or call Ethics Hotline. Adhere to compliance training requirements and understand that training is required condition of employment. Complete tasks accurately and within required timeframes. rn Does this job include responsibilities for directly managing people? YES x NO Does this job require travel? YES x NO If yes, what is the approximate percentage of travel? % Is the travel overnight or local? Minimum Entry Level Qualifications rn Education: Requires a Bachelor’s degree in a Behavioral Health field (Social Work, Psychology, Counseling, Sociology or Nursing). Licenses: N/A Years and Type of Relevant Work Experience: Minimum of two years’ experience supporting clinical staff in a Community Mental Health setting or 5 years in a Behavioral Health clinical service support environment rn #cb #gd

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