DSNP Clinical Assistant-3

We are hiring a Clinical Assistant at BCBST! In this role, you will support BlueCare Plus Clinical Review Managers at BCBST by serving as a key point of contact for providers and healthcare partners. You will assist providers by answering questions, loading authorization faxes, entering authorization requests received by phone, directing providers through the peer-to-peer review process, and ensuring timely, accurate support through both phone interactions and administrative coordination. You will play an important role in improving the overall provider experience by delivering compassionate, member-centered support, responding to inquiries with empathy, and helping ensure smooth coordination of care. The ideal candidate has experience in a medical office setting or working with senior populations. Success in this role requires strong communication skills, patience, attention to detail, and the ability to work independently. Familiarity with medical terminology is preferred. We foster a culture where innovation is encouraged. That includes using AI enabled tools responsibly to support everyday work — guided by proven workflows, templates, and policies. As roles become more advanced, we expect employees to leverage AI more broadly to transform how we serve members. Note: This is a remote role within a collaborative and supportive team environment Candidates must be able to work weekly rotating shifts of 7:30–4:00 p.m., 8:00–4:30 p.m., 8:30–5:00 p.m. and 9:00-5:30 p.m. EST Overtime may be required based on business needs Job Responsibilities Screen incoming calls and/or faxes or other digital format for UM and/or CM and direct calls/faxes/other digital requests to the appropriate area. Identify and refer cases appropriately to the Case Management and/or Transition of Care department. Receiving, investigating and resolving customer inquiries and claims. Maintain departmental goals. Perform projects, review and handle reports as assigned. Load complete organization determination/notification for services designed by internal policy. Clearly document and key data in to the appropriate system using departmental guidelines. Interact with membership, hospital and provider staff, advising of UM decision, status organization determinations, requesting additional or clarifying information and giving direction as necessary. Search for and key appropriate diagnosis and /or procedure code as part of the notification /prior authorization process. This job requires digital literacy assessment. Participation and attendance are mandatory. This position requires flexibility, due to rotations in schedules, and requires adherence to assigned schedules. Work overtime as required Job Qualifications Education High School Diploma or equivalent Experience 1 year - Customer service experience is required Skills\Certifications Proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint) Proficient oral and written communication skills Proficient interpersonal and organizational skills Exceptional time management skills Ability to work independently under general supervision and collaboratively as part of a team in a fast paced environment Independent, Sound decision-making and problem-solving skills If current employee with the company, must meet minimum performance expectations Extensive knowledge of all aspects of Utilization Management, Care Management, and Behavioral Health. Knowledge and understanding of Medical terminology Solid knowledge and understanding of provider reimbursement methodologies, ICD-10-CM, CPT, HCPCS and UB-92 coding, UHDDS coding guidelines, AHA Coding Clinic Ability to talk and type simultaneously in a clear and concise manner while interacting with customers Number of Openings Available 1 Worker Type: Employee Company: VSHP Volunteer State Health Plan, Inc Applying for this job indicates your acknowledgement and understanding of the following statements: BCBST will recruit, hire, train and promote individuals in all job classifications without regard to race, religion, color, age, sex, national origin, citizenship, pregnancy, veteran status, sexual orientation, physical or mental disability, gender identity, or any other characteristic protected by applicable law. Further information regarding BCBST's EEO Policies/Notices may be found by reviewing the following page: BCBST's EEO Policies/Notices BlueCross BlueShield of Tennessee is not accepting unsolicited assistance from search firms for this employment opportunity. All resumes submitted by search firms to any employee at BlueCross BlueShield of Tennessee via-email, the Internet or any other method without a valid, written Direct Placement Agreement in place for this position from BlueCross BlueShield of Tennessee HR/Talent Acquisition will not be considered. No fee will be paid in the event the applicant is hired by BlueCross BlueShield of Tennessee as a result of the referral or through other means.