Medical Management Resolution Specialist

UHS•Reno, NV

About The Position

The Medical Management Resolution Specialist (non-clinical staff) is responsible for monitoring the daily operations with the Medical Management Department, ensuring complete and accurate information is provided on all inquiries and deadlines are met per established departmental policy and procedures, state and federal requirements, and group health plan documents. Medical Management Resolution Specialist are responsible for the initial screening (Intake Process). For initial screening, the organization limits use of non-clinical administrative staff to: Performance of review of service request for completeness of information; collection and transfer of non-clinical data; acquisition of structured clinical data; and activities that do not require evaluation or interpretation of clinical information. The organization ensures that licensed health professionals are available to non-clinical administrative staff while performing initial screening.

Requirements

Ability to effectively communicate in English, both verbally and in writing.
Rudimentary familiarity with Centers for Medicare & Medicaid Services (CMS) guidelines.
Able to work with a diverse multicultural and socioeconomic population.
Familiarity with health care delivery and/or health insurance programs.
Ability to prioritize and multi-task.
Strong problem-solving and critical thinking skills.
Excellent computer skills. Proficient in M/S Office products, including Excel, Word, Access, PowerPoint, and Outlook.
Excellent written and verbal communication skills.
Must be a team player and work autonomously.
Must be innovative, take initiative, and exercise independent judgment and decision making.

Nice To Haves

Associates Degree or higher or equivalent work experience preferred.
Detailed knowledge of CPT/HCPC, ICD-9/10 coding, and medical terminology preferred.
Previous experience in Utilization/Medical Management within a Health Plan environment is preferred.
Must be extremely organized, detail oriented, meet deadlines, and work well under pressure.
Bilingual, optional/preferred but not required.
Empathetic, Caring, Compassionate Listener.
Knowledge of medical claim processing preferred.
Utilization management experience with a various line of business preferred.

Responsibilities

Monitoring the daily operations with the Medical Management Department.
Ensuring complete and accurate information is provided on all inquiries.
Meeting deadlines per established departmental policy and procedures, state and federal requirements, and group health plan documents.
Performing initial screening (Intake Process) including review of service requests for completeness of information, collection and transfer of non-clinical data, and acquisition of structured clinical data.
Interpreting and applying health plan benefits.
Identifying, writing, and/or implementing new processes for better workflow.
Interpreting and adhering to established department policy and procedure as well as all state and federal requirements as it relates to the Utilization Management process.