Medical Management Specialist Senior
Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office. The ideal candidate should be located near one of the following PulsePoints: Woodland Hills-CA, Costa Mesa-CA & Walnut Creek-CA.
Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.
Schedule: This position will work an 8-hour shift from 8:30 am - 5:00 pm (PST), Monday through Friday. Additional hours, including weekends or holidays, may be required based on operational needs.
The Medical Management Specialist Senior is responsible for providing non-clinical support to medical management operations, which includes handling the most complex file reviews and inquiries from members and providers. Provides mentoring and leadership to other medical management specialists.
How you will make an impact:
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.
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.
Acts as liaison between medical management operations and other internal departments to support ease of administration of medical benefits.
Provides mentoring and work direction to lower-level associates.
Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information.
Minimum Requirements:
Requires a H.S. diploma or equivalent and a minimum of 5 years administrative and customer service experience; or any combination of education and experience which would provide an equivalent background.
Preferred Skills, Capabilities, and Experiences:
Knowledge of managed care or Medicaid/Medicare concepts strongly preferred.
Experience with behavioral health or county mental health department is preferred.
Bilingual (English & Spanish) is a plus.
Project oriented experience is desired.
Knowledge of Microsoft Office (Word, PowerPoint, Excel, Outlook, Etc.) preferred.
For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
For candidates working in person or virtually in the below locations, the salary* range for this specific position is $28.70 to $44.93.
Location(s): Woodland Hills-CA, Costa Mesa-CA & Walnut Creek-CA.
In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements).
The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.
Who We Are
Elevance Health is a health company dedicated to improving lives and communities - and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve.
How We Work
At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business.
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.
Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process.
The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws.
Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance.
Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act.
Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration (https://info.flclearinghouse.com/) .
