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 PURPOSEThe Medical Management Representative supports clinical team and serves as a proactive resource for members related to case management and utilization management.ESSENTIAL JOB DUTIESConducts educational telephone calls advising members of available benefits, services and programs; refers members to population health management programs as appropriateReaches 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 interventionFacilitates research and analysis of inquiries and/or complaints and other program related inquiriesFunctions as a liaison to clinical staffCollects and enters data as appropriate to process prior authorization requestsParticipates in projects as neededPerforms duties such as, but not limited to, project research, data entry, and file managementWorks with internal and external persons and/or entities to ensure requests, problems and questions are researched and resolved in a timely mannerWorks overtime as neededRegular and predictable attendanceConsistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practiceWorks to encourage and promote Company culture throughout the organization - waiting on this to be approvedOther duties as may be assignedQUALIFICATIONSHigh School diploma or its equivalentExperience in a customer service role is preferredProficient in Microsoft Office (Outlook, Word, Excel) Fundamentals of Nursing or its equivalentWorking knowledge of NCQA preferred Must be able to work in an independent and creative mannerAbility to manage multiple projects and priorities Adaptive to high pace and changing environment Proficient in interpreting benefits and contract languageKnowledge of medical terminologyPHYSICAL REQUIREMENTSProlonged 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.BENEFITS401K (4% Match, Immediate Vesting) Accident insuranceCompetitive salaryCritical Illness InsuranceDental InsuranceEmployee Assistance ProgramFlexible Spending AccountHealth & Wellness ProgramHealth Savings AccountLife & AD&D InsuranceLong Term DisabilityMedical InsurancePaid Time OffPet InsuranceShort Term DisabilityVision InsurancePRE-EMPLOYMENT SCREENINGDrug Screen and Background Check RequiredHEALTHONE IS AN EQUAL OPPORTUNITY EMPLOYERAll 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.