Medical Management Specialist

Description

BKG Enterprises is seeking Medical Management Specialist to join our team! This is a work-from home opportunity! 

Responsible for providing non-clinical support to medical management operations, which includes handling the most complex file reviews and inquiries from members and providers. Provides mentoring and leadership to other medical management specialists.

Primary duties may include but are not limited to:

• Gathers clinical information regarding case and determines appropriate area to refer or assign case (utilization management, case management, QI, Med Review).
• Conducts initial review of files to determine 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.
• May collaborate with external community-based organizations to facilitate and coordinate care under the direction of an RN Case Manager.
• Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information.
• Acts as liaison between medical management operations and other internal departments to support ease of administration of medical benefits. Provides mentoring and work direction to lower-level associates.
• Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information. Requires a high school diploma and a minimum of 5 years administrative and customer service experience; or any combination of education and experience which would provide an equivalent background. Knowledge of managed care or Medicaid/Medicare concepts 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.

Requirements

•  Requires a high school diploma and a minimum of 5 years administrative and customer service experience; or any combination of education and experience which would provide an equivalent background. Knowledge of managed care or Medicaid/Medicare concepts 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.