Medical Management Specialist

Job Description

Job Description

Position Summary:

The Medical Management Specialist is a dynamic, non-clinical role designed for a resourceful and collaborative healthcare professional seeking a versatile, remote career. At First Choice Health, the Medical Management department prides itself on a supportive, positive culture where team members actively collaborate to help both fellow coworkers and members. Because this position spans multiple core functional areas, it offers an engaging alternative to traditional, repetitive data-entry roles, serving instead as a vital operational hub with significant exposure to the managed care landscape.

The Specialist provides essential administrative support, cross-coverage, and backup across three key areas of the department:

• Case Management Support: Operating under the direct guidance of Nurse Case Managers, this position assists with administrative case creation, conducts targeted member research, and identifies community resources and support programs to assist vulnerable members and caregivers.

• Operational Cross-Coverage: This role serves as a reliable backup for the Intake Coordinator team during peak volumes. Responsibilities include answering inquiries from providers and members via phone, fax, and email, accurately entering authorization data into departmental systems, and efficiently routing complex clinical questions to appropriate reviewers.

• Appeals, Quality, & Operations Support: Partnering with leadership from an administrative perspective, the Specialist assists with continuous Quality initiatives, data retrieval, spreadsheet management, and routine documentation maintenance required for ongoing URAC accreditation standards.

This position requires a highly motivated, assertive, and self-managed individual who possesses the confidence to proactively ask questions and clarify expectations without requiring micromanagement. It represents an ideal growth opportunity for a professional with a solid foundation in health insurance operations who is eager to expand their skillset across case management, intake, appeals, and quality assurance. The core operational hours for this full-time position are Monday through Friday, 8 am to 5 pm Pacific Time.

Examples of Duties:

Case Management Support

• Performs non-clinical administrative functions to set up Case Management files.

• Meet productivity requirements.

• Conducts targeted research on member benefits, health coverage, or history to assist the clinical team.

• Educates members on the value of Case Management services during initial onboarding.

• Other projects or duties as assigned.

Intake Operations & Departmental Cross-Coverage

• Logs into the telephonic call center to provide intake backup during peak volumes or staffing gaps.

• Responds to incoming calls, faxes, and emails regarding prior authorizations and care inquiries.

• Accurately enters authorization requests into the Casetrakker system.

• Collaborates with the clinical team to route complex clinical questions or urgent requests efficiently.

• Maintains strict data security, ethical conduct, and excellent customer service.

Appeals, Quality, & Operations Support

• Supports the Clinical Appeals Coordinator with non-clinical processing, tracking, and correspondence.

• Executes administrative data retrieval, spreadsheet management, and routine tracking for Quality initiatives.

• Assists with year-round documentation maintenance required for URAC accreditation.

• Communicates effectively with internal departments and external customers (such as providers and members) to solve problems.

• Participates in team meetings, conference calls, and special projects.

Qualifications

• Education: High School Diploma or equivalent required; BA/BS in a healthcare-related field preferred.

• Experience: Minimum of two (2) years in a healthcare environment. We welcome applicants from diverse medical administration or clinical support backgrounds; relevant examples include roles such as Medical Assistant, Medical Receptionist, Front Desk Coordinator, Intake Clerk, or equivalent positions where navigating healthcare systems is required.

• Industry Knowledge: Solid understanding of health insurance benefits and general healthcare delivery. Prior exposure to medical terminology, case management functions, or basic CPT/ICD coding is highly preferred.

• Technical Skills: Strong proficiency in PC applications (Microsoft Office/Word/Excel and Google Workspace). Experience organizing, filtering, and managing data within spreadsheets is required. Project-based or data-tracking experience is preferred.

• Core Competencies:

• Self-Management: Ability to work independently and manage shifting priorities with minimal direction.

• Assertiveness: Proactive communication style; comfortable asking clarifying questions and collaborating across teams.

• Communication: Excellent written, verbal, and telephone customer service skills.

Physical & Remote Workspace Requirements

• Dedicated, HIPAA-compliant home office with a secure, reliable internet connection meeting company standards.

• Ability to see and hear within normal ranges with or without aid.

• Ability to remain stationary for long periods.

• Manual and finger dexterity.

• Ability to bend, move, and lift a minimum of 10–20 pounds.

Access to PHI

• This position requires regular, unrestricted, and routine access to all forms of PHI.

The core operational hours for this full-time position are Monday through Friday, 8 am to 5 pm Pacific Time