Medical Management Specialist I

3 weeks ago


Kapolei, Hawaii, United States HMSA Full time
Job Summary

We are seeking a highly skilled Medical Management Specialist I to join our team at HMSA. As a key member of our operations team, you will play a critical role in ensuring the smooth processing of clinical review requests and vendor authorization files.

Key Responsibilities
  • Clinical Review Requests: Evaluate, interpret, and process clinical review requests, ensuring compliance with internal policies, contractual provisions, and regulatory requirements.
  • Vendor Authorization Files: Process vendor authorization files, researching and validating existing authorizations, and updating them as necessary.
  • Customer Service: Respond to inquiries, issues, or complaints from providers and members, applying Ulysses Call Strategy servicing skills and escalating calls as needed.
  • Aerial to QNXT (A2Q) Error/Balance Reports: Accurately build UMD documents within QNXT to support claims processing activities and notify issues associated with the A2Q process.
  • Clinical Review Requests via Online Authorization Tool: Apply internal policies and procedures, contractual provisions, and regulatory requirements, and triage and distribute cases to respective units.
Requirements

To be successful in this role, you will need to have excellent analytical and problem-solving skills, as well as strong communication and customer service skills. You will also need to be able to work effectively in a fast-paced environment and prioritize multiple tasks and deadlines.

We offer a competitive salary and benefits package, as well as opportunities for professional growth and development. If you are a motivated and detail-oriented individual who is passionate about delivering exceptional customer service, we encourage you to apply for this exciting opportunity.



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