Medical Management Specialist I

Pay Range: $37,715 - $54,447

Note: Individuals typically begin between the minimum to middle of the pay range

• Evaluation, interpretation, and processing of clinical review requests to include but not limited to applying the following requirements:
  
  • Validation that requests has met submission requirements based on accreditation / governmental regulation requirements.
  • Educate and/or communicate with provider offices on appropriate procedures.
  • Application of internal policies and procedures, contractual provisions, and regulatory requirements.
  • Multi-system validation of member specific eligibility, benefit and provider requirement for selected service(s) based on member's primary line of business.
  • Utilization of various resources to confirm HMSA's clinical review requirements; as required, educate and/or respond to provider office with outcome.
  • Creation of the electronic file within the Utilization Management (UM) management system for review.
  • Adhering to the guidelines and processes for management of documents within the Fax Manager Application (FMA).

• Process vendor authorization files to reflect the appropriate decisions within HMSA's system to appropriately and accurately impact claims processing to include but not limited to the following:
  
  • Researching, validate and update existing authorizations based on extensions, peer to peer reviews and updates requested from provider community.
  • Monitoring and addressing errors as a result of the request program load feature.
  • Notify and/or communicate issues associated with authorization files with unit coordinator, supervisor or UM Solutions Administrator.

• Resolve, document and accurately respond to inquiries, issues or complaints received telephonically from provider (and members) by:
  
  • Application of Ulysses Call Strategy servicing skills.
  • Researching multiple system and/or online document resources
  • Contacting 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's level of concern, knowledge required to respond in an accurate manner.

• Processing of the Aerial to QNXT (A2Q) error / balance reports by:
  
  • Accurately building UMD documents within QNXT to support the claims processing activities.
  • Notify and/or communicate issues associated with A2Q process to unit coordinator, supervisor or UM Solutions Administrator.

• Monitor and processing of clinical review requests received via online authorization tool by:
  
  • Applying internal policies and procedures, contractual provisions and regulatory requirements.
  • Multi-system validation of member specific eligibility, benefit and provider requirement for selected service(s) based on member's primary line of business.
  • Triaging and distribution of the cases to the respective units taking into account type of service, place of treatment, provider relationship and line of business.

• Performs all other miscellaneous responsibilities and duties as assigned or directed.

• Associate's degree or equivalent combination of education and work experience.

• Good customer service skills.

• Working knowledge of basic office equipment.

• Strong verbal communication skills.

• Good written communication skills to document actions/conversations with customers clearly and precisely.

• Understanding of CPT/HCPCS coding and medical terminology.

• Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, and Outlook.