Medical Management Specialist II

4 weeks ago

Topeka, Kansas, United States Elevance Health Full time
Job Title: Medical Management Specialist II

Job Summary:

We are seeking a highly skilled Medical Management Specialist II to join our team at Elevance Health. As a Medical Management Specialist II, you will play a critical role in providing non-clinical support to medical management operations, handling complex file reviews and inquiries from members and providers.

Key Responsibilities:


  • Gathers clinical information regarding cases and determines the appropriate area to refer or assign the case (utilization management, case management, QI, Med Review).
  • Conducts initial reviews of files to determine the 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 a liaison between medical management operations and other internal departments to support the ease of administration of medical benefits.
  • May assist with case referral processes.
  • 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 referrals to local CCS programs on the same date of identification of potential CCS eligible conditions.
  • Tracks referrals 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 that require the interpretation of clinical information.


Requirements:


  • Requires a high school diploma and a minimum of 3 years of administrative and customer service experience; or any combination of education and experience that would provide an equivalent background.


Preferred Skills, Capabilities, and Experiences:


  • Knowledge of managed care or Medicaid/Medicare concepts is strongly preferred.


Work Environment:

This position will work in a hybrid model (remote and office). The ideal candidate will live within 50 miles of our Topeka, Kansas Elevance Health PulsePoint location.

About Elevance Health:

Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work:

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes, and drive our shared success - for our consumers, our associates, our communities, and our business.

Benefits:

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.

Equal Employment Opportunity:

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.

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