Anthem, Inc. Medical Mgmt Specialist II in Miami Lakes, Florida
SHIFT: Day Job
Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.
This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health care companies and a Fortune Top 50 Company.
Responsible for providing non-clinical support to medical management operations, which includes handling more complex file reviews and inquiries from members and providers.
Primary duties may include, but are not limited to:
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.
Requires a high school diploma; 3 years of administrative and customer service experience with knowledge of managed care or Medicaid/Medicare concepts; or any combination of education and experience, which would provide an equivalent background.
For URAC accredited areas the following applies: Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
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. Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.