Position Purpose: Evaluate, design, develop and implement medical management initiatives to support the business needs through various clinical analysis
Develop and analyze various clinical data and reports on medical management programs, including authorization, utilization and case/disease management
Develop databases, set benchmarks, identify root cause and recommend improvements
Develop, create and implement database or automation to support and eliminate manual updates to programs within medical management
Research, identify and monitor provider utilization trends and monitor providers for adherence to contract provisions. Report trends and refer cases for further investigation
Conduct audits and ensuring consistency with all contractual requirements
Respond to all inquiries related to provider assignments
Establish criteria and strategy for pilot programs and advise on guidelines and system modifications that affect claims processing and payment decisions
Bachelor’s degree in Healthcare, Business, Quantitative science or related field.
4+ years business or clinical data analysis.
Experience with medical coding practices, groupers and reimbursement practices.
Comprehensive knowledge of current medical practices covering a broad range of medical specialties especially neonates and newborns.
Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff. Provider and claim systems (CCMS and Amisys) experience preferred.
Knowledge of ICD-9, DRG’s and CPT codes preferred.
About the Company:
A Fortune 500 company, is a diversified, multi-national healthcare enterprise that provides a portfolio of services to government sponsored healthcare programs, focusing on under-insured and uninsured individuals. Many receive benefits provided under Medicaid, including the State Children's Health Insurance Program (CHIP), as well as Aged, Blind or Disabled (ABD), Foster Care and Long Term Care (LTC), in addition to other state-sponsored/hybrid programs, and Medicare (Special Needs Plans).
The Company operates local health plans and offers a range of health insurance solutions. It also contracts with other healthcare and commercial organizations to provide specialty services including behavioral health management, care management software, correctional healthcare services, dental benefits management, in-home health services, life and health management, managed vision, pharmacy benefits management, specialty pharmacy and telehealth services.
The company offers more than just medical insurance. They pay most of your benefits costs and in some cases – they pay 100 percent. Most of the benefits not covered by the company are paid with pre-tax payroll deductions.
Flexible spending accounts (includes health care, dependent care mass transit reimbursement)
Short- and long-term disability insurance
Basic Life insurance
Supplemental life insurance
401(k) retirement with company match
Employee stock purchase plan
Vacation, Personal and Sick time
Paid Company Holidays
Employee Assistance Program (EAP)
Training and Learning Opportunities
Tuition Reimbursement/Educational Assistance
On-site fitness center or discount at local fitness centers (most locations)
Discounts for select local and national products and services, including cell phones, computers and more
Other amenities may be available, but vary by location