Medical Management Specialist I

Medical Management Specialist I

Medical Management Specialist I

Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office. The ideal candidate will be located near one of the following Pulsepoints: Miami-FL, Tampa-FL or Lake Mary-FL.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

Schedule: This position will work an 8-hour shift from 8:00 am - 5:00 pm (EST), Monday through Friday. Additional hours, including weekends or holidays, may be required based on operational needs.

The Medical Management Specialist I is responsible for providing non-clinical support to the Medical Management and/or Operations areas.

How you will make an impact:

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.
• Regularly interacts with providers regarding authorization related inquiries.
• 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.

Minimum Requirements:

• Requires a H.S. diploma or equivalent and a minimum of 1 year experience or any combination of education and experience which would provide an equivalent background.

Preferred Skills, Capabilities, and Experiences:

• Fully Bilingual (English & Spanish/Creole). Must be able to write, read and speak both languages in a proficiency level preferred.
• Understanding of managed care or Medicaid/Medicare strongly preferred.
• Previous experience in healthcare industry and customer service is a plus.
• Previous experience working with LTSS members or Medicaid is 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.

Job Level: Non-Management Non-Exempt

Workshift: 1st Shift (United States of America)

Job Family: MED > Medical Ops & Support (Non-Licensed)