Medical Management Specialist I

Medical Management Specialist I

Albuquerque, New Mexico

Job Reference ID: - 49383

Category: Registered Nurse/LPN, Case Manager

Job Type: Right To Hire

Pay Rate: $43.93

Job Description:

This position is responsible for review of the daily inpatient report to 1) assess member health conditions, specifically pregnancy and/or post partum conditions, 2) identify care coordination (CC) needs, utilizes platforms such as Synchrony's, NM state portal to communicate inpatient admissions to each impacted delegate, and support the transition of care process. This position also supports ad-hoc provider communications based on various internal and external requirements, reviews and responds to the shared Delegated Care Coordination Entity (DCCE) mailbox, including supporting Health Coordinators (HC), engages Project Management (PM) support as needed. Partners closely with the DCCE PM to support new delegate onboarding and trainings including training material development, onsite and virtual training facilitation, participation in Joint Operations Committee meetings, including delegation oversight, and Food Is Medicine initiatives, member assignment and unassignment process, development and execution of a monthly compliance oversight process, and participation in a related Data Analyst Team (DAT) work group conducting medical management and health education programs for customers on government health care programs. This role will include gathering, analyzing and providing data for regulatory reports. This position will represent the company to members.

Job Purpose:

This position is responsible for conducting medical management and health education programs for customers on government health care programs. Accountabilities include gathering, analyzing and providing data for regulatory reports. This position will represent the company to members.

Job Qualifications:

• Registered Nurse (RN), with 3 years direct clinical care to the consumer in a clinical setting. Current, valid, unrestricted license in the state of operations (or reciprocity). For compact licensee changing permanent residence to state of operations, you must obtain active, unrestricted RN licensure in the state of operations within 90 days of hire.
• Plus 3 years wellness or managed care experience presenting clinical issues with members/physicians.
• Knowledge of the health and wellness marketplace and employer trends.
• Verbal and written communication skills including discussing medical needs with members and interfacing with internal staff/management and external vendors and community resources.
• Analytical experience including medical data analysis.
• Current driver's license, transportation and applicable insurance.
• Ability and willingness to travel within assigned territory.
• PC proficiency to include Word, Excel, and PowerPoint, database experience and Web based applications

Preferred Job Qualifications:

• 3 years clinical experience
• Patient education experience.
• Condition Management experience
• Bilingual in English and Spanish.
• Transition of Care experience.
• Experience in managing complex or catastrophic cases.
• Certification in Case Management, Training, Project Management or nationally recognized health care certification.