Judge Healthcare is seeking a Clinical Operations Specialiste for one of our top clients in the Independence, MO area.
Position Details:
Title: Clinical Operations Specialist
Location: Independence, MO 64056
Type of Engagement: Contract 6+ months
Specific Duties:
Performs routine administrative workflow tasks that support functions of Clinical Operations. Identifies cases for internal and external Clinical programs.
Uses various communication methods to identify and solicit information from providers and vendors as relevant to clinical and business need.
Coordinates, reviews and investigates claims to determine the medical necessity and appropriateness of the care
Determines simple cases that require review by Medical Director, Pharmacist or nurse.
Interprets medical review results to determine compliance with contract provisions.
Reports suspicions of compliance, clinical, quality, and regulation concerns
Identifies cases for care and cost management
Recommend benefit allowances in alignment with contract liabilities
Actively engages in communication and response with internal and external customers regarding care management, products, and services
Directs processing of contractual benefits after investigation is complete
Escalates complex cases to senior team member.
Requirements/Qualifications:
Requires two years (60 credit hours) of college or 2 years of healthcare experience.
Experience using InterQual is required.
Additional years of qualifying work experience may be considered in lieu of formal education.
Requires intermediate proficiency with technology applications and systems.
Requires experience using Microsoft office products, i.e., Outlook, Excel, Word, Teams.
Requires effective written and verbal communication skills.
Functions as part of the MMD Member Experience team, managing incoming calls and faxes from members and providers
Preferred experience taking inbound calls and making outbound calls.
Work hours: M-F, 40 hours a week, CST time zone
Please send your updated resume and the job number to Sophia Kranias at SCosciaKranias@judge.com for immediate consideration.
Thank you for your time and I look forward to hearing from and working with you.
Regards,
Sophia Kranias
Healthcare Recruiter
The Judge Group
Phone: 610-784-8213
Contact: scosciakranias@judge.com
This job and many more are available through The Judge Group. Find us on the web at www.judge.com
