HP1 TOC

Position Summary:

The Health Professional 1 provides telephonic customer service and timely resolves inquiries regarding patient care, eligibility, benefits, and claims, among others. This key individual provides follow up for patients to assure continuity of care and efficiency of overall services. This employee is not responsible for conducting any UM review activities that require interpretation of clinical information.

Essential Functions:

1. Verifies patient eligibility and arranges appointments when needed.

2. Provides assistance via verbal and written correspondence for subscribers, patients-relatives, providers, account representatives, among others.

3. Authorizes initial patient care per the company’s policies and procedures.

4. Performs telephonic non-clinical referrals for customers. Performs data entry and timely documents of all calls.

5. Conducts investigation and research to resolve customer inquiries, claims and questions.

6. Performs follow up calls to ensure effective patient care and provision of services.

7. Communicates actively with internal staff such as Care Managers, Supervisors and other department managers.

8. Use of clinical data is limited to: Performance of review of service request for completeness of information; Collection and transfer of non-clinical data; and Acquisition of structured clinical data; and Activities that do not require evaluation or interpretation of clinical information.

9. Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable.

10. In addition, all other duties assigned by the manager and/or supervisor.

Education:

Bachelor’s Degree in Behavioral Health or related field preferred.

Experience:

Minimum 2 years of experience in customer service in a behavioral health or managed care environment preferred.

Knowledge:

Knowledge and ability to interpret benefit, account and claim information.

Proficient in data entry.

Personal computer experience should include working with Microsoft Word, Excel, Power Point and Outlook at the intermediate level at a minimum.