Clinical Solutions Associate II

Paradigm is an accountable specialty care management organization focused on improving the lives of people with complex injuries and diagnoses. The company has been a pioneer in value-based care since 1991 and has an exceptional track record of generating the very best outcomes for patients, payers, and providers. Deep clinical expertise is the foundation for every part of Paradigm’s business: risk-based clinical solutions, case management, specialty networks, home health, shared decision support, and payment integrity programs.

SUMMARY:

This position holds accountability for the successful administrative partnership with the Director Clinical Services (DCS) and the Network Manager (NWM) in the overall management of contracts. This includes tracking of all customer deliverables that meet targeted timelines and reflect and support patient management, facilitation of patient management team communication and general support of both the Network Manager and the Director Clinical Services to ensure proactive and well-conceived management plans. In addition, the Clinical Services Associate II holds an administrative accountability, in partnership with Network Services, to designated Network Business Owners (or designees) to reinforce their full understanding and support of Paradigm process and direction.

DUTIES AND RESPONSIBILITIES:

• Partner with Director Clinical Services to manage the development of all new contracts, including participation in clinical conferences, tracking of appropriate documents and development of budget and financials associated with the contract.
• Participate and /or facilitate and document results of all patient related conferences as requested by the Director Clinical Services.
• Research and document patient driven costs and provider rates that drive budget development and management. Utilize web driven and other electronic resources to identify potential costs, including use of CPT codes in the company’s electronic claims adjudication system.
• Ensure smooth administrative management of all assigned Paradigm cases, including tracking and routing of patient reimbursement requests, PRNs, PNFs and PCA requests.
• Track all customer deliverables to ensure timely submission that meet company Standards of Performance. Initiate appropriate action plans for late reports or contracts.
• Provide instruction to the administrative team regarding the entry of accurate patient demographic data in the electronic data collection system.
• Participate in the report review process as required by established workflow procedures.
• Serve as primary point of administrative contact for case specific Network Manager, including providing information and direction regarding deliverable timelines, budget and provider management, as well as appropriately managing and directing case specific requests and inquiries from the Network Manager, patient/family or provider.
• Liaise with assigned administrative Network Business contacts, providing education regarding Paradigm internal process, product revision or implementation and specific Network Manager performance issues.
• Collaborate with other internal departments (Contracting, Bill Review, Accounting) to address and resolve specific patient / provider issues.
• Participate in procedural and workflow development for the CSA team as well as the overall Clinical Operations team.
• Participate in company projects requiring CSA II representation, as requested by management.
• The case load is equitably distributed among all CSA II roles.
• All CSA II will participate in the creation of and adopt CSA best practices.
• The CSA team is expected to provide backup coverage for each other as requested by the manager.
• Responsible for complying with Paradigm IT security requirement and policies.
• Responsible for safeguarding Paradigm or Paradigm related IT passwords.
• Responsible for notifying Paradigm of any IT security incidents per policy 16.0 Information Security Incident Management.
  
  
  

QUALIFICATION REQUIREMENTS: To perform this job successfully an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Education: Bachelor’s degree from an accredited educational institution preferred.
• Experience: Three to five years progressively responsible customer service experience. Three years related experience in provider relations or health care. Strong medical background to include comprehensive understanding of medical terminology and health care principles and practices. Demonstrated ability to multi-task in a fast paced work environment. Experience with various computer applications including Microsoft Office, Outlook, Word and Excel.
• Language: Excellent oral communication skills and phone presence. Ability to read and comprehend instructions, correspondence, memos, and medical/patient reports. Ability to write correspondence and memos and utilize e-mail communication effectively. Ability to present information in one-on-one and small group situations.
• Reasoning Ability: Excellent analytical skills -- ability to define problems, collect data, establish facts, and draw valid conclusions; ability to interpret a variety of instructions and deal with abstract and concrete variables; demonstrated ability to analyze difficult situations, problems, and data; use good judgment and decision making.
• Any combination of education/experience and knowledge that demonstrates the ability to perform the functions of the position will be accepted.
  
  
  

Paradigm believes that fostering a diverse and inclusive workplace is central to our mission of helping more people and transforming lives. We’re striving to build a culture that better reflects the society we live in and empowers our team to deliver the highest levels of compassion and care to those we serve. For us, achieving this goal requires a workforce that respectfully embraces differences and commits to positive change, creating an environment where everyone is able to bring their whole self to work.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.