Clinical Operations Specialist
Judge Group
Independence, MO
Salary: $26.00 USD Hourly - $30.00 USD Hourly
Description:
- Performs routine administrative workflow tasks that support functions of Clinical Operations. Identifies cases for internal and external Clinical programs.
- Uses various communication methods to identify and solicit information from providers and vendors as relevant to clinical and business need.
- Coordinates, reviews and investigates claims to determine the medical necessity and appropriateness of the care
- Determines simple cases that require review by Medical Director, Pharmacist or nurse.
- Interprets medical review results to determine compliance with contract provisions.
- Reports suspicions of compliance, clinical, quality, and regulation concerns
- Identifies cases for care and cost management
- Recommend benefit allowances in alignment with contract liabilities
- Actively engages in communication and response with internal and external customers regarding care management, products, and services
- Directs processing of contractual benefits after investigation is complete
- Escalates complex cases to senior team member.
- Requires two years (60 credit hours) of college or 2 years of healthcare experience.
- Experience using InterQual is required.
- Additional years of qualifying work experience may be considered in lieu of formal education.
- Requires intermediate proficiency with technology applications and systems.
- Requires experience using Microsoft office products, i.e., Outlook, Excel, Word, Teams.
- Requires effective written and verbal communication skills.
- Functions as part of the MMD Member Experience team, managing incoming calls and faxes from members and providers
- Preferred experience taking inbound calls and making outbound calls.
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Contact: scosciakranias@judge.com
About the Company
Judge Group
The Judge Group Inc., is a leading professional services firm specializing in talent, technology, and learning solutions. We consult, staff, train, and solve. Through our work we make people and organizations better. Our services are successfully delivered through a network of more than 30 offices across the United States, Canada, and India.
The Judge Group is proud to partner with the best and brightest companies in business today, including over 60 of the Fortune 100. We serve organizations in financial services, healthcare, life sciences, insurance, government (including aerospace and defense), manufacturing, and technology and telecommunications. If you would like to learn more about The Judge Group visit www.judge.com or call toll free (800) 360-4474.