Responsibilities
- Communicate and provide education to members and providers on insurance plan benefits and digital health solutions.
- Use negotiation and motivational interviewing techniques to increase engagement.
- Pro-active and reactive support for members, including outbound phone/email/text outreach.
- Employ active listening & motivational interviewing skills, and can handle difficult calls tactfully, courteously, professionally and document accordingly that can build patient trust and engagement.
- Ability to effectively excel in a virtual work environment through active participation in team huddles, Supervisor 1:1s, Instant Messaging, or check-ins, efficiently answering and documenting member/provider calls.
- Accurately track and document work on a variety of internal software tools and platforms.
- Consult with supervisors, utilization management team, medical directors, as needed to overcome barriers.
- Effectively manages escalations within the department by ensuring appropriate accountability, sense of urgency, communication and follow through to closure.
- Assist departmental staff with coding, medical records/documentation, pre-certification, reimbursement, and claim denials/appeals.
- Ability to interact with external facility or providers as needed to gather clinical information to support the medical necessity review process and plan of care.
Requirements
- 1-2 years of experience working at a health plan, preferably with a commercial population.
- 3-5 years of nursing experience in a clinical setting assisting with direct patient care, such as a hospital or ambulatory setting.
- Must have Spanish fluency (conversational).
- Must have a current, unrestricted Texas nursing license or Compact License.
- Diploma from an accredited school/college of nursing required.
- You have working knowledge of medical and insurance industry terminology including basic understanding of health plan benefits, CPT/ICD10, authorizations, and digital health programs.
Nice to Have
- Familiarity with Salesforce/Healthcloud/CareIQ.
- Experience working in a call center.
Benefits
- Competitive salary
- Comprehensive health, dental, and vision insurance as well as life and disability
- Retirement savings plan with company match
- Generous time off/vacation
- Professional development opportunities
- Flexible and remote work environment
