Healthcare Operations Specialist

3 weeks ago


Rancho Cordova, California, United States Blue Shield of California Full time

Overview of the Role

The Blue Shield Clinical Service Coordinator Advanced will support clinical staff in day-to-day operations for Promise (Medi-Cal) and Commercial/Medicare lines of business. In this role, you will be responsible for timely and accurate processing of Treatment Authorization Requests.

Your Responsibilities

  1. Work in a production-based environment with defined production and quality metrics to ensure regulatory turnaround standards are met.
  2. Process requests from providers and members through various channels, including fax, web portal, phone, and voicemail.
  3. Selectively assign initial Extension of Authority days or triage to nurses based on established workflow guidelines.
  4. Assist Case Managers with mailings, surveys, and data entry related to authorization forms, high-risk member information, and verbal HIPAA authorizations.
  5. Support Intermediate and Specialist CSCs as needed.
  6. Research member eligibility, benefits, and provider networks to facilitate smooth medical management processes.
  7. Serve as the primary point of contact for providers and members through telephone or correspondence.
  8. Collaborate with medical management teams to provide administrative/clerical support.
  9. Conduct intake, data entry, and system updates in a fast-paced environment.
  10. Provide guidance to offshore representatives on workflow procedures.
  11. Perform other duties as assigned by management.

Requirements

  • Requires a high school diploma or equivalent.
  • At least 5 years of prior relevant experience in healthcare operations.
  • May require vocational or technical education in addition to work experience.
  • Prior experience with Medicare, Medi-Cal, and utilization management is preferred.
  • In-depth knowledge of non-clinical business rules and guidelines in pre-service, inpatient, DME, and home health settings.
  • Familiarity with systems like AuthAccel, Facets, AEVS, and PA Matrix or similar tools.
  • Ability to communicate complex workflows to offshore staff and adapt to high-pressure environments.
  • Knowledge of UM regulatory TAT standards and clinical workflows.

Salary and Benefits

The estimated salary range for this position is $27,455 - $38,295 per year in California, depending on experience and location. Blue Shield salaries are competitive and based on various factors, including candidate qualifications and current employee salaries for similar roles within the organization.



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