Weekend Rotation on Saturdays: Once every 12 weeks Holiday Coverage: All holidays except Thanksgiving day and Christmas day
Build the Possibilities. Make an Extraordinary Impact.
The Medical Management Specialist IIis responsible for providing non-clinical support to medical management operations, which includes handling more complex file reviews and inquiries from members and providers.
How you will make an impact:
Primary duties may include, but are not limited to:
Gathers clinical information regarding case and determines appropriate area to refer or assign case (utilization management, case management, QI, Med Review).
Conducts initial review of files to determine appropriate action required.
Maintains and updates tracking databases.
Prepares reports and documents all actions.
Responds to requests, calls or correspondence within scope.
Provides general program information to members and providers as requested.
May review and assist with cases.
Acts as liaison between medical management operations and other internal departments to support ease of administration of medical benefits.
May assist with case referral process.
May collaborate with external community-based organizations to facilitate and coordinate care under the direction of an RN Case Manager.
For California Children Services: May request medical records from providers, may complete and submit CCS referral to local CCS program on same date of identification of potential CCS eligible condition.
Tracks referral according to specified timelines and notifies providers and families of CCS eligibility determinations and referrals, BCC authorizations and/or deferrals.
Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information.
Reviews and processes letters to facilities on adverse determinations made by Medical Directors.
Possess excellent organizational skills to manage work in a production environment to meet minimum realistic expectations for production.
Meeting turnaround times for letter processing, and accurate with correct grammar, spelling, punctuation, to complete final letters that go to providers.
Minimum Requirements:
Requires a H.S. diploma or equivalent and a minimum of 3 years administrative and customer service experience; or any combination of education and experience which would provide an equivalent background.
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
Preferred Skills, Capabilities and Experiences:
Knowledge of managed care or Medicaid/Medicare concepts is strongly preferred
Extensive knowledge of medical terminology preferred
Experience in systems such as ACMP, AUMI, Facets preferred
