Full Time, Employee

Harrisburg, PA

The Clinical Support Specialist I and II/Sr. Clinical Support Specialist is responsible for working within their assigned Medical Management unit to perform tasks assigned by the Clinical Team Lead.

The assigned activities include, but not limited to the following: utilizing computer systems to research pertinent information regarding eligibility and benefits of members, construction of case structure through entering pertinent information into the computer systems and providing telephone support for members and providers to assist in answering questions pertinent to the activity of the assigned Medical Management unit. Provides administrative support to the Medical Management department is inclusive of the Preauthorization, Medical Claims Review, Concurrent Review and appeals units.


1. Responsible for maintaining unit service level goals.
2. Conducts intake services, including the coordination between the units within the Clinical Management Department.
3. Processes referrals/requests/records received for services and forwards to the appropriate member of the team after researching and/or verifying member eligibility and benefit information.
4. Provides telephone support to the unit for assigned queue.
5. Provides eligibility and claims status support, both internally and externally, for non-clinical issues relating to specific cases.
6. Performs administrative duties to support the core functions of the unit, as requested, such as taking meeting minutes, monitoring office equipment to assure operating order, mails and distributes various letters created by staff, scheduling meetings, purging files, and faxing.
7. Acts as the Records Point of Contact for assigned Unit.
8. Promotes personal growth through participation in staff meetings, appropriate in-services and corporate training.
9. Complies with established departmental policies and desktop procedures.
10. Works as a respectful member of the team in a collaborative manner to complete duties and to solve problems.
11. Demonstrates the ability to be detail oriented and accurate with assigned work.
12. Identifies opportunities for improvement of overall functioning of the unit to develop more efficient processes and to move the business forward.
13. Assists in the orientation of new employees.
14. Provides special project assistance as needed.
15. Completes any special assignments/reports in a complete and timely manner.
16. Participates in the development of desktop procedures related to position.


1. Possesses a high school diploma or G.E. D. with 2 to 3 years experience in the medical health field (e.g., medical assistant, medical secretary) or 2 to 3 years experience in a managed care clinical department.
2. Working knowledge of medical terminology.
3. Able to demonstrate competence with and/or ability to learn various health plan computer systems (e.g., FACETS, Impact Pro, FEP, CAIC, CCA and Image).
4. Working knowledge of the insurance industry, health plan benefits and product lines (e.g., PPO, POS, HMO, FEP, Senior Products, Traditional/Comprehensive).
5. Excellent customer service skills in order to work with internal and external customers, and ability to communicate effectively both verbally and in writing.
6. Strong organizational skills with the ability to be flexible and prioritize workload based on departmental needs.
7. Must have quality standards and capability to produce and record information with attention to detail, accuracy and within time standards established by the Sr. Team Lead/Manager.
8. Able to perform basic mathematical calculations (e.g. addition, subtraction, multiplication and division).
9. Experienced utilizing a PC and various software packages (e.g., Microsoft Office Suite) with keyboarding skills equivalent to 40 words per minute.
10. Knowledge of regulatory and accreditation standards and requirements preferred. (e.g., NCQA, URAC, Pennsylvania Department of Health and Department of Insurance, ERISA, Act 68).
11. Preferred experience in a managed care organization with specific experience related to clinical management.