Medical Management Specialist I


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Reference Code: 4845

Position:  Medical Management Specialist I, HCSCJP00013011
Contract to Hire
Location Address: Springfield, Illinois 62704


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

1. Implement appropriate Health Care Management client specific custom strategies and programs, to enhance population health care outcomes and Case Management Programs. Develop a relationship with members to facilitate implementation of our health management programs. Works in an independent manner and may handle complex cases.
2. Collaborate with the client, internal Medical Director and health care management operations in meeting established turn around times.
3. Facilitate and implement action plans to support activities, coordinating with internal and external resources to meet program targets and objectives.
4. Facilitate communications with management related to potential client issues; proactively working with the client and internal operations to resolve any client issues.
5. Collaborate with internal operations on marketing materials to promote health education programs, to include content for the Web site.
6. Collect and maintain data needed for reporting and prepare required reports on production activity, survey results and other content applicable to the program. Assist in ensuring appropriate outcomes reporting on standards. Assist in the monitoring of trends, generate recommendations, and implement interventions for improvement. Collect and maintain data needed for reporting and prepare required reports on production activity, survey results and other content applicable to the program.
7. Assist in the implementation and evaluation of effectiveness of population based health education programs.
8. Use professional judgment and departmental guidelines to refer cases for chronic and catastrophic review and to physician reviewers.
9. Assess cases for quality of care or refer cases to the physician advisors for review and follow up.
10. Cooperate with other members of the department and interfacing departments as a team to decrease costs, coordinate benefits, and provider services, and quality to subscribers.
11. Consult with physicians, providers, members, and other resources, as appropriate, to assess, plan, facilitate implementation, coordination, monitor and evaluate options and services required to meet an individual’s health needs, using communication and available resources to promote quality, cost effective outcomes.
12. Collaborate with Medical Director as necessary when developing treatment plans for members.
13. Counsel pre-admission members with selected diagnoses to address questions on treatment plan, discharge planning, and recovery.
14. Obtain consent and conduct comprehensive Condition Management for those members meeting the Condition Management criteria and ensure enrollment in the Condition Management programs as appropriate.
15. Develop alternate plans and assists member/provider to navigate the health care system while optimizing benefits. Refer care option to contracted providers.
16. Conduct post-discharge survey calls to provide member with education regarding:
? Expected recovery
? Identifying any barriers to recovery
? Encouraging physician follow-up appointments
? Ensure medications are obtained if ordered
? Ensure therapies are completed if ordered
? Provide member education regarding approved websites:
a. health risk assessment
b. health content
c. decision making tool kit
d. education sites for relevant health information
e. health risk assessment
f. health content
g. decision making tool kit
h. education sites for relevant health information
17. Practice within the scope of licensure within the state regulations and with the URAC/NCQA accreditation standards.
18. Attend monthly/quarterly meetings as requested.
19. Support & promote health initiatives and be knowledgeable of applicable benefit programs
20. Participate/facilitate in various classes/meetings designed for the members.
21. Handle project management or implementation of initiatives and/or train new Medical Management Specialists or other staff.
22. Any additional special projects, initiatives or meetings as requested.
23. Communicate and interact effectively and professionally with co-workers, management, customers, etc.
24. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
25. Maintain complete confidentiality of company business.
26. Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

? Registered Nurse (RN), Licensed Professional Counselor (LPC), or Licensed Master Social Worker (LMSW) with 2 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 5 years wellness or managed care experience presenting clinical issues with members/physicians.
? Experience handling medical management programs and health educations programs in an independent manner.
? 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.
? PC proficiency to include Word, Excel, and PowerPoint, database experience and Web based applications.
? Leadership skills in project management and/or training.
? Nationally recognized health care certification.

? 3 years clinical experience.
? Patient education experience.
? Condition Management experience.
? Bilingual in English and Spanish.
? Experience in managing complex or catastrophic cases.
? Certification in Case Management.



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