Medical Management Specialist

Job Description This position supports the workflow of the Medical Services division. The Medical Services Coordination Specialist provides support for any of the programs of Behavioral Health, Quality Management, or Member Care Management. This position is responsible for adhering to certain regulatory requirements as well helping to support and connect members to appropriate internal Health Plan resources, Clinical Case Management team and external community support systems. Essential Accountabilities LevelI Review and prep clinical case for clinical staff. Assess member’s needs by applying Health Plan approved case management guidelines and assessment tools. Makes appropriate referrals to clinical programs. Collaborate with the clinical care team to support enrollees. Work with enrollee/caregiver/legal guardian to identify and achieve shared treatment goals. Manage a caseload productively and keep appropriate documentation according to health plan standards. Provide advocacy for members and their support systems, encourage self-sufficiency by addressing social determinants of health, provide effective coaching, and place referral to case and disease management as needed. Link enrollees with resources and empower them to use them to their advantage. Ensure that referrals result in timely appointments. Monitor member engagement and follow up on outstanding actions to ensure closure of care gaps and completion of required assessments. Engage members via multiple communication channels (phone, messaging, digital tools) to support improved health outcomes. Explore multiple sources of information to identify members who have a gap in care, aligning with HEDIS quality measures and Value Based Payment Programs. Communicate effectively to provide outreach and education for members on health care quality metrics, assess barriers to care, and intervene as appropriate to assure access or facilitate referrals to other services for the purpose of improving healthcare (i.e. access to care, preventive health, chronic diseases, and health equity). Coordinate enrollees’ access to transportation, pharmacy, grocery store, food pantry and other community resources, as needed, to meet care plan goals. Prepare and assist in handling member and provider correspondence related to disease conditions and/or care management program services. Ensure accuracy and timeliness of processing. Manage relevant BH/MCM/Quality voice and email inboxes and/or Stored Information retrieval (SIR) queues throughout day for messages, potential care management referrals, and relevant clinical documentation. Adhere to unit Service Level Agreements (SLA), internal and external regulatory commitments, and regulatory timeframes to meet expectation of state partners. Ensure end-to-end process for care management referrals is accurate and complete by collaborating with other internal departments. Non‑care manager support staff duties may include requesting medical records, mailing of educational materials, answering and responding to telephone calls, e‑mails, etc. as long as they are non‑clinical in nature. Perform intake assessment and triage functions for each call to appropriate MCM/Quality service area. Provide preliminary support to multiple levels of providers (and others as needed), including but not limited to physicians, skilled nursing facilities, mid‑level providers and members. Communicate to the members and service providers according to regulatory agency requirements and/or organizational guidelines. Consistently demonstrate high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct and Lifetime Way Values and Beliefs. Maintain high regard for member privacy in accordance with the corporate privacy policies and procedures. Regular and reliable attendance is expected and required. Perform other functions as assigned by management. LevelII (in addition to LevelI Accountabilities) Prioritize work and provide instruction, advice and guidance to more junior staff as it relates to the assigned unit’s processes, procedures and business systems. Support training and onboarding of new staff. Mentor newer staff and troubleshoot unit‑related questions. Serve as an intermediary between staff and management to alert leadership of potential barriers or challenges. Review and bring forward recommendations to ensure desk level procedures and process workflows remain current and relevant. Produce care management statistics on a daily and as needed basis for department‑related metrics: case and review timeliness, workflow volumes, referrals generated to care management programs. LevelIII (in addition to LevelII Accountabilities) Assist supervisor with control and monitoring of inventory levels of assigned department, according to established priorities and performance standards. Assist supervisor with monitoring and evaluating workflow to ensure timeliness and unit standards are met. Provide reporting, analysis and recommendations to unit management based on day‑to‑day and observed experience. Assist in updating departmental policies, procedures and desk level procedures relative to the department functions. Identify and develop processes and guidelines for performance improvement, productivity and efficiency gains. Handle complex issues, escalated customer questions, high maintenance or priority customers for the assigned business unit, high dollar/high‑cost member investigation. Assess staff and unit training needs and report this information to the supervisor. Identify eligibility and coverage and assist other staff and other areas within the company with related inquiries. Collaborate with internal departments regarding changes in processes/systems and identify problems and recommend logical and effective solutions. Minimum Qualifications All Levels Minimum of one year experience working in an insurance company, medical assistant or Health Plan customer service, delivering care coordination at a community‑based organization or working within a patient‑facing medical care setting required. Working knowledge of medical terminology. Demonstrate proficiency with Microsoft Office Suite. Excellent oral and written communication skills. Demonstrated organizational and interpersonal skills; able to manage multiple tasks under pressure. Ability to utilize department specific applications and software: care management system and department libraries. Ability to utilize engagement strategies to connect with population served (i.e., motivational interviewing, etc.). Attention to detail. LevelII (in addition to LevelI Qualifications) Minimum of three years’ experience working in an insurance company, delivering care coordination at a Community Based Organization, or medical care setting required. Ability to develop and apply in‑depth knowledge of complex rules, such as care management systems and processes, departmental policies and procedures, product lines, and regulatory requirements. Broad understanding of multiple areas of the company and willingness to develop collaborative solutions to achieve a better end‑to‑end process. Ability to recognize sensitive issues and/or significant areas of concern and when to elevate to management. Demonstrated ability to lead committee activities and support newer team members. Consistently exceed minimum productivity standards as set out by department. Ability to find opportunities for process improvement and participate in resolution of more complex issues/activities. LevelIII (in addition to LevelII Qualifications) Minimum of five years of experience working in an insurance company or medical care setting required. Thorough knowledge and understanding of health plan contracts, regulatory requirements, and unit procedures. Knowledgeable in multiple systems and/or processes that allow for effective and efficient identification of data or process issues to resolve related issues. Ability to precept new staff, take on more complex challenges, flexibility and independence in work assignments, and participation in meetings and special projects. Ability to identify process efficiencies and develop plan of action to implement. Demonstrated presentation skills. Physical Requirements Ability to work prolonged periods sitting and/or standing at a workstation and working on a computer. Ability to work while sitting and/or standing at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time. Ability to work in a home office for continuous periods of time for business continuity. Ability to travel across the Health Plan service region for meetings and/or trainings as needed. The ability to hear, understand, and speak clearly while using a phone, with or without a headset. Compensation Range(s) LevelI: N3: Minimum: $20.40 – Maximum: $27.00 LevelII: N4: Minimum: $20.80 – Maximum: $30.80 LevelIII: N5: Minimum: $21.20 – Maximum: $33.03 In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. #J-18808-Ljbffr