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Medical Management Specialist I

2 months ago

Kapolei, Hawaii, United States Hawaii Medical Service Association Full time
Job Summary

**Hybrid Work Environment Required**

Pay Range: $42,000 - $68,000

**About the Role**

We are seeking a highly skilled Medical Management Specialist I to join our team at Hawaii Medical Service Association. As a key member of our Utilization Management (UM) program, you will play a critical role in ensuring the efficient and effective management of healthcare services.

Key Responsibilities

  • Evaluation and Processing of Clinical Review Requests
    • Validate requests against submission requirements based on accreditation and governmental regulation requirements.
    • Educate and communicate with provider offices on appropriate procedures.
    • Apply internal policies and procedures, contractual provisions, and regulatory requirements.
    • Multi-system validation of member-specific eligibility, benefit, and provider requirements for selected services based on the member's primary line of business.
    • Utilize various resources to confirm HMSA's clinical review requirements and educate or respond to provider offices as needed.
    • Creation of electronic files within the UM management system for review.
  • Vendor Authorization Files
    • Research, validate, and update existing authorizations based on extensions, peer-to-peer reviews, and updates requested from the provider community.
    • Monitor and address errors resulting from the request program load feature.
    • Notify and communicate issues associated with authorization files with the unit coordinator, supervisor, or UM Solutions Administrator.
  • Provider and Member Inquiries
    • Resolve, document, and accurately respond to inquiries, issues, or complaints received telephonically from providers and members.
    • Apply Ulysses Call Strategy servicing skills.
    • Research multiple systems and online document resources.
    • Contact unit leads or resources for additional explanation.
    • Triage and transfer calls to appropriate areas upon request or require a subject matter expert (SME).
    • Escalate calls as appropriate, taking into account urgency, customer level of concern, and knowledge required to respond accurately.
  • Aerial to QNXT (A2Q) Error/Balance Reports
    • Accurately build UMD documents within QNXT to support claims processing activities.
    • Notify and communicate issues associated with A2Q process to the unit coordinator, supervisor, or UM Solutions Administrator.
  • Clinical Review Requests via Online Authorization Tool
    • Apply internal policies and procedures, contractual provisions, and regulatory requirements.
    • Multi-system validation of member-specific eligibility, benefit, and provider requirements for selected services based on the member's primary line of business.
    • Triaging and distribution of cases to respective units, taking into account type of service, place of treatment, provider relationship, and line of business.
  • Other Responsibilities
    • Perform all other miscellaneous responsibilities and duties as assigned or directed.