Medical Management Specialist II

Location: Kansas. This position will work in a hybrid model (remote and office). The ideal candidate will live within 50 miles of our Topeka, Kansas Elevance Health PulsePoint location.

The Medical Management Specialist II is responsible for providing non-clinical support to medical management operations, which includes handling more complex file reviews and inquiries from members and providers.

How you will make an impact:

• Gathers clinical information regarding case and determines appropriate area to refer or assign case (utilization management, case management, QI, Med Review).
• Conducts initial review of files to determine appropriate action required. Maintains and updates tracking databases.
• Prepares reports and documents all actions. Responds to requests, calls or correspondence within scope.
• Provides general program information to members and providers as requested.
• May review and assist with cases.
• Acts as liaison between medical management operations and other internal departments to support ease of administration of medical benefits.
• May assist with case referral process.
• May collaborate with external community-based organizations to facilitate and coordinate care under the direction of an RN Case Manager.
• For California Children Services: May request medical records from providers, may complete and submit CCS referral to local CCS program on same date of identification of potential CCS eligible condition.
• Tracks referral according to specified timelines and notifies providers and families of CCS eligibility determinations and referrals, BCC authorizations and/or deferrals.
• Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information.

Minimum Requirements:

• Requires a high school diploma and a minimum of 3 years administrative and customer service experience; or any combination of education and experience which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences:

• Knowledge of managed care or Medicaid/Medicare concepts 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.

Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Who We Are

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.

How We Work

At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. Candidates must reside within 50 miles or 1-hour commute each way of a relevant Elevance Health location.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.