Medical Management Specialist II at Elevance Health in Indianapolis, Indiana

Job Description:

Title: Medical Management Specialist II



*This position will be 100% remote*




Location: IN-INDIANAPOLIS, 220 VIRGINIA AVE


Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.



Shift: 8:30am - 5:00pm EST, Monday - Friday (8 hour shift)


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.
  
  

• 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.
  
  

• 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