Medical Management Specialist I

Job description

#LI-Hybrid - Evaluation, interpretation, and processing of clinical review requests to include but not limited to applying the following requirements: - Validation that requests has met submission requirements based on accreditation / governmental regulation requirements. - Educate and/or communicate with provider offices on appropriate procedures. - Application of internal policies and procedures, contractual provisions, and regulatory requirements. - Multi-system validation of member specific eligibility, benefit and provider requirement for selected service(s) based on member's primary line of business. - Utilization of various resources to confirm HMSA's clinical review requirements; as required, educate and/or respond to provider office with outcome. - Creation of the electronic file within the Utilization Management (UM) management system for review. - Adhering to the guidelines and processes for management of documents within the Fax Manager Application (FMA). - Process vendor authorization files to reflect the appropriate decisions within HMSA's system to appropriately and accurately impact claims processing to include but not limited to the following: - Researching, valida...