Medical Management Specialist I

Evaluation, Interpretation, and Processing of Clinical Review Requests

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 services based on members primary line of business.

Utilization of various resources to confirm HMSAs 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 HMSAs system to appropriately and accurately impact claims processing to include but not limited to the following:

• Researching, validate, and update existing authorizations based on extensions, peer to peer reviews, and updates requested from provider community.
• Monitoring and addressing errors as a result of the request program load feature.
• Notify and/or communicate issues associated with authorization files with unit coordinator, supervisor, or UM Solutions Administrator.

Resolve document and accurately respond to inquiries, issues, or complaints received telephonically from provider and members by:

• Application of Ulysses Call Strategy servicing skills.
• Researching multiple system and/or online document resources.
• Contacting unit leads or resources for additional explanation.
• Triage and transfer calls to appropriate areas upon request or require a subject matter expert (SME).
• Escalate calls as appropriate, taking into account urgency, customers level of concern, knowledge required to respond in an accurate manner.

Processing of the Aerial to QNXT (A2Q) error balance reports by:

• Accurately building UMD documents within QNXT to support the claims processing activities.
• Notify and/or communicate issues associated with A2Q process to unit coordinator, supervisor, or UM Solutions Administrator.

Monitor and processing of clinical review requests received via online authorization tool by:

• Applying internal policies and procedures, contractual provisions, and regulatory requirements.
• Multi-system validation of member specific eligibility benefit and provider requirement for selected services based on members primary line of business.
• Triaging and distribution of the cases to the respective units, taking into account type of service, place of treatment, provider relationship, and line of business.

Performs all other miscellaneous responsibilities and duties as assigned or directed.

LI-Hybrid