Medical Management Specialist

2 weeks ago


Indianapolis, United States Professional Management Enterprises Full time
Job DescriptionJob DescriptionDescription:

BKG Enterprises is seeking Medical Management Specialist to join our team This is a work-from home opportunity


Responsible for providing non-clinical support to medical management operations, which includes handling the most 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.
  • May collaborate with external community-based organizations to facilitate and coordinate care under the direction of an RN Case Manager.
  • Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information.
  • Acts as liaison between medical management operations and other internal departments to support ease of administration of medical benefits. Provides mentoring and work direction to lower-level associates.
  • Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information. Requires a high school diploma and a minimum of 5 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 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.
Requirements:
  • Requires a high school diploma and a minimum of 5 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 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.


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