Hybrid CNA Healthcare Management Specialist

Purpose:
In the Healthcare Management department, the HCM Support Rep will be responsible for telephone communications with insureds, providers, and other outside sources as required. The Support Rep will be responsible for the creation of pre-notifications and other administrative duties to support the HCM department. Using knowledge of medical
terminology, ability to understand medical records, and basic policy provisions in the Certificates, as well as developing a familiarity with benefits of insureds will be a strong focus of this position. The Support Rep will also develop a working knowledge of the various computer systems and software packages used in the department.

• Call Management: Handle 60-70 calls daily, with around 80% being inbound. Engage with members, provider offices, providers, and insurance agents to address various inquiries.
• Information Gathering: Collect and verify discharge dates, prior authorization types, and demographic and insurance information from members. Ensure this information is accurately relayed to providers.
• Prenotification Process: Assess the need for prenotification during calls. Provide direct contact information for follow-up if prenotification is required. Ensure accurate system setup when the date of service is known.
• Data Entry: Enter and manage demographic information, CPT codes, and ICD codes into the system. Utilize provided software programs for data entry and follow established protocols.
• Clinical and Insurance Queries: Understand and request necessary clinical information without quoting benefits directly (RNs handle benefit quotations). Knowledge of reference-based pricing (RBP) versus PPO is essential.
• Technical Support: Operate effectively using computer systems and software. Maintain personal computer for remote work until a company-provided computer is available.

Requirements:

• Tech Savvy: Proficient with computer systems and software. Must have a personal computer for remote work.
• Clinical Background: Certified Nursing Assistant (CNA) license or recent relevant experience in a healthcare setting
• Pricing Knowledge: Understanding of reference-based pricing (RBP) and its differences from PPO models.
• Phone Experience: Experience managing high-volume phone calls and handling stressful situations with professionalism.
• Good Phone Etiquette: Strong communication skills and ability to manage tough calls with empathy and professionalism.