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Medical Management Specialist I

2 months ago

Kansas City, United States Professional Management Enterprises Full time

Job Title: Medical Management Specialist
Location: Remote (Missouri)
Hours: 8am - 5pm Monday - Friday
Pay: $18.50hr **Weekly Pay**

Primary duties may include but are not limited to: Gathers clinical information, triages/builds cases, determines appropriate area to refer or assign case (utilization management, case management, Med Review). Provides information regarding network providers or general program information when requested by provider. Communicates with providers regarding additional information or scheduling peer to peers. Maintains and updates tracking databases. Prepares reports and documents all actions. Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information.

  • Staffing the provider line for escalations to various departments
  • gathering clinical information regarding the case from the provider and determining appropriate area to refer to
  • Provides information about network providers, builds authorizations and other non-clinical support as needs arise
  • Maintains and updates tracking tools/databases and documents all interactions in the medical management platform
  • Assisting company with resolving provider escalations and scheduling peer to peer conversations
  • Confirming member's eligibility with each interaction
  • Creating authorizations and disseminating to the correct department in accordance with service level agreements
  • Provide accurate, valid, and complete information by using the right methods/tools
  • Meet personal/customer service team targets and call handling quotas
  • Handle customer complaints, provide appropriate solutions and alternatives within the time limits; follow up to ensure resolution
  • Keep records of customer interactions, process customer accounts and file documents
  • Follow communication procedures, guidelines, and policies
  • Take the extra mile to engage customers
  • Ability to create and maintain a professional remote work environment/area
  • Requires a H.S. diploma or equivalent and a minimum of 1 year experience or any combination of education and experience which would provide an equivalent background. Understanding of managed care or Medicaid/Medicare 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.

    PME is an equal opportunity employer. We prohibit discrimination and harassment against any applicant or employee based on any legally recognized basis, including, but not limited to: veteran status, uniformed servicemember status, race, color, religion, sex, sexual orientation, gender identity, age (40 and over), pregnancy, national origin or ancestry, citizenship status, physical or mental disability, genetic information (including testing and characteristics) or any other category protected by federal, state or local law.