Medical Management Resolution Specialist

Responsibilities

Prominence Health is a value-based care organization bridging the gap between affiliated health systems and independent providers, building trust and collaboration between the two. Prominence Health creates value for populations and providers to strengthen integrated partnership, advance market opportunities, and improve outcomes for our patients and members. Founded in 1993, Prominence Health started as a health maintenance organization (HMO) and was acquired by a subsidiary of Universal Health Services, Inc.

(UHS) in 2014. Prominence Health serves members, physicians, and health systems across Medicare, Medicare Advantage, Accountable Care Organizations, and commercial payer partnerships. Prominence Health is committed to transforming healthcare delivery by improving health outcomes while controlling costs and enhancing the patient experience.

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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.

• Loan Forgiveness Program
• Challenging and rewarding work environment
• Competitive Compensation & Generous Paid Time Off
• Excellent Medical, Dental, Vision and Prescription Drug Plans
• 401(K) with company match and discounted stock plan
• SoFi Student Loan Refinancing Program
• Career development opportunities within UHS and its 300+ Subsidiaries!
  * More information is available on our Benefits Guest Website:

One of the nation's largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. During the year, UHS was again recognized as one of the World's Most Admired Companies by Fortune; and listed in Forbes ranking of America's Largest Public Companies. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom.

• 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.
• Language
  
  Skills:
  
  Ability to effectively communicate in English, both verbally and in writing.
• Skills:
  
  Rudimentary familiarity with Centers for Medicare & Medicaid Services (CMS) guidelines.
• Bilingual, optional/preferred but not required.
• Empathetic, Caring, Compassionate Listener.
• 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.
• Knowledge of medical claim processing preferred.
• Utilization management experience with a various line of business preferred.
• 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.
• Ability to interpret and apply health plan benefits.
• Demonstrate the ability to identify, write, and/or implements new processes for better workflow.
• Ability to interpret and adhere to established department policy and procedure as well as all state and federal requirements as it relates to the Utilization Management process.

* Must work PST hours*

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color,…