Medical Management Specialist II at Elevance Health in NORFOLK, Virginia

Job Description:

Title: Medical Management Specialist II



Location: This position will work a remote model, but candidates must live within 50 miles of one of our PulsePoint locations.



Shift: 4 weekdays and 1 weekend day as discussed with manager.


The Medical Management Specialist II is 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.
  
  

• 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.