Position Title:

Medical Management Specialist I/ PHRN

Shift:

Job Description:

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. Requires a current Philippines RN license; 1 year of administrative and customer service experience with knowledge of managed care or Medicaid/Medicare concepts; or any combination of education and experience, which would provide an equivalent background. 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.