Medical Management Specialist II
Location: This position works on a hybrid model. While primarily remote, candidate would need to come into our office (101 Wood Ave S, Iselin, NJ) at least once a week.
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.
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 high school diploma and a minimum of 3 years administrative and customer service experience; or any combination of education and experience which would provide an equivalent background.
- Knowledge of managed care or Medicaid/Medicare concepts is strongly preferred.
- 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.
Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Be part of an Extraordinary Team
Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. A Fortune 20 company with a longstanding history in the healthcare industry, we are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide - and Elevance Health approves - a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health has been named as a Fortune Great Place To Work in 2022, has been ranked for five years running as one of the 2023 World's Most Admired Companies by Fortune magazine, and is a growing Top 20 Fortune 500 Company. To learn more about our company and apply, please visit us at careers.ElevanceHealth.com. Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact email@example.com for assistance.