Central Health

HCS Program Specialist

Req No.
Sendero Health Plans
Job Locations
Regular Full-Time


Works within the Healthcare Services (HCS) team to provide clerical and data entry support for members that require hospitalization and/or utilization review for other healthcare services.  Checks eligibility and verifies benefits, obtains and enters data into systems, processes requests, and triages members and information to the appropriate HCSs staff to ensure the delivery of integrated high quality, cost-effective healthcare services according to State and Federal requirements to achieve optimal outcomes for Members. Also supports the HCS team by providing telephonic outreach and assessment for members through programs designed to improve health outcomes and maintain wellness.  Works collaboratively with the HCS team to reach members and provide them with wellness and condition management programs designed to improve clinical, financial and quality of life outcomes.


  • Provide computer entries of authorization request/provider inquiries by phone, mail, or fax. Including: 
    • Verify member eligibility and benefits, 
    • Determine provider contracting status and appropriateness, 
    • Determine diagnosis and treatment request
    • Assign billing codes (ICD-9/ICD-10 and/or CPT/HCPC codes), 
    • Determine COB status, 
    • Verify inpatient hospital census-admits and discharges,
    • Perform action required per protocol using the appropriate Database.
  • Meet department productivity standards with minimal errors. 
  • Respond to requests for authorization of services submitted via phone, fax and mail according to operational timeframes. 
  • Participates in interdepartmental integration and collaboration to enhance the continuity of care for members including Behavioral Health.
  • Contact physician offices according to Department guidelines to request missing information from authorization requests or for additional information as requested by the Medical Director.
  • Provide excellent customer service for internal and external customers.
  • Meet department quality standards, including inter-rater reliability (IRR) testing and quality review audit scores.
  • Notify nurses and case managers of hospital admissions and changes in member status.
  • Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
  • Participate in HCS meetings as an active member of the team.
  • Meet attendance guidelines per policy.
  • Follow “Standards of Conduct” guidelines as described in HR policy.
  • Comply with required workplace safety standards.
  • Initiates and receives telephone calls to enroll members in relevant wellness and condition specific programs.
  • Perform appropriate telephonic Health Risk Assessments (HRAs) with members. 
  • Conducts outreach and telephonic screening of members to identify needs for Case Management programs. 
  • Obtains and validates member demographic information as needed.
  • Tracks, monitors and maintains an ongoing log for mailed surveys.
  • Provides back-up telephone coverage and administrative support such as generating letters, and preparing envelopes for mail out as needed. 
  • Offers referral information to members as needed such as member services telephone number, provider phone number, etc.
  • Maintain records of outreach and received calls, distributed materials, assessments completed and referrals made for reporting purposes.
  • Provides assistance in improving HEDIS scores for the health plans, by performing outbound calls to members who have not received services for validation of HEDIS measures and/or appointment scheduling to get those services.
  • Serves as a resource as needed, by providing a variety of member outreach calls and/or provides coverage to ensure required regulatory projects are met.
  • Provides support to the HCS staff performing non clinical activities and supporting the management of the department.
  • Screens members using policies and processes assisting clinical HCS staff as they identify appropriate medical services
  • Coordinates required services in accordance with member benefit plan. 
  • Promotes communication, both internally and externally to enhance effectiveness of HCS. 
  • Provides support services to HCS team members by answering telephone calls, taking messages and researching information.
  • Maintains accurate and complete documentation of required information that meets risk management, regulatory, and accreditation requirements. 
  • May assist in the research and resolution of claims payment issues.


  • Demonstrated ability to communicate, problem solve, and work effectively with people.
  • Working knowledge of medical terminology and abbreviations.
  • Ability to think analytically and problem solve.
  • Good communication and interpersonal/team skills.
  • Ability to work in a fast paced environment.
  • Able to work independently and as part of a team. 
  • Computer skills and experienced user of Microsoft Office software.
  • Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers
  • Computer skills and experience with Microsoft Office Products. 
  • Knowledge of office equipment and procedures.
  • Flexibility, willingness to learn new responsibilities
  • Willingness to work in a constantly changing environment.


MINIMUM EDUCATION:  High School Diploma or GED

MINIMUM EXPERIENCE:  Proficient Computer Skills


PREFERRED EXPERIENCE:  One year or more in a Utilization Review Department in a Managed Care Environment. Previous Hospital or Healthcare clerical, audit or billing experience. Experience with Medical Terminology.

PREFERRED CERTIFICATIONS/LICENSURE:  Certification in Coding, auditing or billing


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