- Demonstrate commitment and behavior aligned with the philosophy, mission, values and vision of Network Health.
- Appropriately apply all organizational, regulatory, and credentialing principles, procedures, requirements, regulations, and policies.
- Enters authorization/pre-determination requests into information system according to Network Health policies, procedures and desk references. Authorization requests include but may not be limited to anything listed on the NHP/NHIC/NHAS list of services requiring prior authorization.
- Assign case and condition candidates received via referrals/triggers to appropriate Care or Condition Management Coordinator.
- Interact with member, practitioner/provider, or other entities via telephone calls, faxes, emails or letters related to authorizations, case management, claims and benefit inquiries
- Collect member or provider specific information telephonically or electronically as requested.
- Assist in mentoring of new employees as needed.
- May assist with other non-clinical projects and tasks when needed.
- Other duties as assigned.
- High School Diploma
- Two (2) years of health care experience in clinical or insurance setting required.
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Population Health Specialist II - Menasha, United States - Network Health Plan (Wisconsin)
3 weeks ago
Description
Network Health's success is rooted in its mission to create healthy and strong Wisconsin communities. It drives the decisions we make, including the people we choose to join our growing team. Network Health is seeking a Population Health Specialist II. This individual will process Network Health (NHIC/NHP/NHAS) authorization requests in accordance with established guidelines and triages authorization workflow. Assists with Case Management assignment of candidates and operational support. Assists with supporting and monitoring compliance with CMS/Federal regulatory and NCQA standards related to the authorization processes.
Provides operational support for the Case, Condition Management, Quality, Wellness, Pharmacy, Government Relations, and Utilization Management Departments including, but not limited to requesting and extracting medical records and provider outreach for HEDIS, Health Risk Assessments, Primary Care Provider Attributions, and CIOX medical records. The population health specialist II may also be responsible for various outbound member calls, including by not limited to new welcome calls, service recovery opportunities, etc.
Job Responsibilities:
Network Health is an Equal Opportunity Employer. We encourage applications from all backgrounds, communities and industries, and are committed to having a team that is made up of diverse skills, experiences and abilities. We are committed to equality and diversity within Network Health.
