Department: Medical Support
Position: Clinical Support Specialist
Employee Category: Non-Exempt
Reporting Relationship: Practice Administrator
Character Qualities:
- Compassion—showing genuine care and concern for patients and their well-being.
- Reliability—consistently following through on commitments and maintaining dependable performance.
- Attention to Detail—carefully reviewing and processing information to ensure accuracy and quality.
- Adaptability—adjusting effectively to changing clinical protocols and patient needs.
- Teamwork—collaborating effectively with healthcare providers and support staff to achieve common goals.
Summary of Duties and Responsibilities:
Provides clinical support in key functions such as prior authorizations, equipment orders (DME), and other duties that support key clinical workflows in the delivery of patient care. This role ensures that efficient processes are in place, for example, communication and authorizations are obtained to continue delivery of care.
Primary Duties and Responsibilities:
- Assists healthcare providers in obtaining approvals by payors in areas such as medications, prior authorizations of procedures and medical equipment.
- Manages the providers documents to ensure key actions are taken to obtain medication Prior Authorizations, DME equipment, or medical procedures.
- Reviews key documentation in patients' medical record to obtain clinical information pertinent to obtain approval.
- Accesses key databases such as Cover My Meds, OptumRx to obtain approvals and payor websites needed to receive approvals.
- Proficient in EPIC charting, documentation, in-basket management, WQ management.
- Contacts outside agencies and patients to ensure that appropriate patient care is completed.
- Contacts patients to schedule follow up appointments after approvals are obtained and communicates any payment responsibility on their behalf.
- Keep patients informed of progress or if any additional requests are needed for approval.
- Communicates with providers and medical support team on progress or additional documentation required.
- Meets productivity standards and processes all requests in a timely manner.
- Supports quality improvement initiatives and participates in clinical audits as requested.
- Communicates effectively with patients and providers regarding approvals or denials.
- Keeps the providers informed of progress of prior authorizations and DME orders with documentation required.
- Manages the prior authorizations and DME orders for medical service lines of pediatrics, women’s health and family medicine or dental.
- Assists with coordination of outside medical requests and ensures timely communication with specialist providers.
- Participates in staff meetings and continuing education opportunities.
- Maintains confidentiality of patient information in accordance with HIPAA regulations.
- Supports clinic operations during provider absences or high-volume periods.
- Establishes and maintains cooperative working relationships within the organization and community.
- Supports Variety Care’s accreditation as a Patient Centered Medical Home and our commitment to provide care to all Variety patients that is Safe, Effective, Patient Centered, Timely, Efficient, and Equitable. Provide leadership and work with all staff to achieve the goals of the “Quintuple Aim” of healthcare reform—to improve the experience of care, improve health outcomes, and decrease healthcare costs.
- Embodies the strength of personal character. Places value on being an open and honest communicator who displays high moral and ethical conduct, integrity, adaptability, and sound judgment. Must be a leader in the department and community. Result-oriented problem solver who is responsible and accountable.
- Performs other duties as assigned.