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Anthem, Inc. Medical Management Specialist II in Miami, Florida

Description

SHIFT: Day Job

SCHEDULE: Full-time

Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.

his is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health care companies and a Fortune Top 50 Company.

Medical Management Specialist I Responsibilities:

Responsible for providing non-clinical support to the Medical Management and/or Operations areas. 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).

  • Provides information regarding network providers or general program information when requested.

  • May assist with complex cases.

  • May act as liaison between Medical Management and/or Operations and internal departments.

  • Maintains and updates tracking databases.

  • Prepares reports and documents all actions.

  • Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information.

    Medical Management Specialist II Responsibilities:

    Responsible for providing non-clinical support to medical management operations, which includes handling more complex file reviews and inquiries from members and providers. 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.

  • Acts as liaison between medical management operations and other internal departments to support ease of administration of medical benefits.

  • May assist with case referral process.

  • 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 referral to local CCS program on same date of identification of potential CCS eligible condition.

  • Tracks referral 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 which require interpretation of clinical information.

Qualifications

Medical Management Specialist I Minimum Requirements:

  • High school diploma or GED equivalent

  • Minimum of 1 year experience with an understanding of managed care or Medicaid/Medicare; or any combination of education and experience which would provide an equivalent background.

    Medical Management Specialist I Preferred Qualifications:

  • For URAC accredited areas the following applies: Strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills preferred.

    Medical Management Specialist II Minimum Requirements:

  • High school diploma or GED equivalent

  • Minimum of 3 years administrative and customer service experience; or any combination of education and experience which would provide an equivalent background.

    Medical Management Specialist II Preferred Qualifications:

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

  • For URAC accredited areas, the following professional competencies apply: Associates with strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills preferred.

    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. Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.

    REQNUMBER: PS62618-Florida

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