Medical Management Representative

MISSION Our mission is to enhance well-being by connecting individuals with vital health resources through a compassionate workforce that embodies the spirit of neighbors helping neighbors. VALUES HealthOne is guided by a cultural framework that embodies our values and drives our decisions. Our PURPOSE is to care for people by connecting them to resources that help protect them in health related situations. To fulfill our purpose, we align our PRIORITIES to ensure each decision we make is ethical, empathetic, economical, and efficient. We care for PEOPLE by being welcoming, authentic, truthful, consistent and humble. We are continuously looking for ways to improve our PROCESS and how we get things done. HealthOne seeks individuals with integrity and heart to embody our values. Whether you’re starting your career or looking to develop additional skills to reach your full potential, HealthOne provides the means to help you achieve your goals. JOB PURPOSE The Medical Management Representative supports clinical team and serves as a proactive resource for members related to case management and utilization management.

ESSENTIAL JOB DUTIES Conducts educational telephone calls advising members of available benefits, services and programs; refers members to population health management programs as appropriate Reaches out to members with identified gaps in care to provide assistance in securing provider(s) and arranging appointment(s) Manages system work queues; screening identified members for eligibility, prior case activities, recent claims, customer service inquiries and authorization history; assigning members to clinical team for call outreach and intervention Facilitates research and analysis of inquiries and/or complaints and other program related inquiries Functions as a liaison to clinical staff Collects and enters data as appropriate to process prior authorization requests Participates in projects as needed Performs duties such as, but not limited to, project research, data entry, and file management Works with internal and external persons and/or entities to ensure requests, problems and questions are researched and resolved in a timely manner Works overtime as needed Regular and predictable attendance Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice Works to encourage and promote Company culture throughout the organization - waiting on this to be approved Other duties as may be assigned QUALIFICATIONS High School diploma or its equivalent Experience in a customer service role is preferred Proficient in Microsoft Office (Outlook, Word, Excel) Fundamentals of Nursing or its equivalent Working knowledge of NCQA preferred Must be able to work in an independent and creative manner Ability to manage multiple projects and priorities Adaptive to high pace and changing environment Proficient in interpreting benefits and contract language Knowledge of medical terminology PHYSICAL REQUIREMENTS Prolonged periods of sitting at a desk and working on a computer. Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day responsibilities. Must be able to drive a vehicle and daytime/overnight travel as required. BENEFITS 401K (4% Match, Immediate Vesting) Accident insurance Competitive salary Critical Illness Insurance Dental Insurance Employee Assistance Program Flexible Spending Account Health & Wellness Program Health Savings Account Life & AD&D Insurance Long Term Disability Medical Insurance Paid Time Off Pet Insurance Short Term Disability Vision Insurance PRE-EMPLOYMENT SCREENING Drug Screen and Background Check Required HEALTHONE IS AN EQUAL OPPORTUNITY EMPLOYER All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, disability, sex, age, ethnic or national origin, marital status, sexual orientation, gender identity or presentation, pregnancy, genetics, veteran status or any other status protected by state or federal law.