Medical Management Job Description
Medical management
provides medical management through communication with the Physician Utilization Management Advisor (PUMA), other health care providers and referral sources.
Medical Management Duties & Responsibilities
To write an effective medical management job description, begin by listing detailed duties, responsibilities and expectations. We have included medical management job description templates that you can modify and use.
Sample responsibilities for this position include:
Review medical records for PIP precertification auto injury claims to establish medical necessity and causal relationship
Monitor vendor compliance with requirements, as directed
Review files and invoices to evaluate appropriate levels of care and medical payments, quality control of the medical aspects of PIP or Workman's Compensation claims management
Review files and invoices to evaluate compliance with applicable statutory and regulatory requirements, industry best practices
The individual will have responsibility for the Medical Management committee functions (HQUM, Provider Relations)
Provides guidance on determination of medical appropriateness through the application of clinical criteria
Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards laborites with providers to assess members needs for early identification of and proactive planning for discharge planning
Supports medical management of UnitedHealthcare Global members in both domestic and global healthcare environments
Coordinate internal resources to ensure the flawless execution of multiple launch-critical projects, such as publications, IT integration of medical functions, build of call center
Ensure that the planning and execution of launch initiatives are delivered on time and within budget
Medical Management Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Medical Management
List any licenses or certifications required by the position: CPR, BLS, AHA, CCBMA, AMCA, NCCT, AMT, AAMA, PMP, RN
Education for Medical Management
Typically a job would require a certain level of education.
Employers hiring for the medical management job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Education, Nursing, Management, Medical, Healthcare, Performance, Healthcare Administration, Medical Terminology, Microbiology, Biochemistry
Skills for Medical Management
Desired skills for medical management include:
Member benefits
Managed care products
Medical management process and ability to interpret and apply member contracts
Health and wellness marketplace and employer trends
Medical terminology
Managed care
Medicaid/Medicare concepts
Member and providers contracts
Utilization management and cost containment strategies
All utilization management programs
Desired experience for medical management includes:
3 years of progressive experience in case or utilization management
Effective verbal/written communication and interpersonal
Demonstrated case management knowledge
Successful portfolio experience is preferred
Education level normally acquired with the completion of an AA degree, business school or equivalent work experience
2 years’ experience in a customer centered office or agency with experience in utilization management, case management, disease management, or customer service preferred
Medical Management Examples
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Medical Management Job Description
Job Description Example
Our company is searching for experienced candidates for the position of medical management. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for medical management
- Draft vital launch-focused internal presentations and communicate key information effectively
- Professionally interface with vendors and manage to agreed-upon timelines as needed
- Create and implement new approaches to deliver communications and content
- Establish timeline and process to ensure Medical Affairs annual and long-range planning are efficient
- Ensure Medical Affairs adherence to industry/corporate/department/function regulations, policies, and procedures
- Be creative by challenging usual industry standards of practice
- Act as ambassador for Medical Affairs function across entire organization
- Inspire and drive the Medical Affairs team to collectively meet or exceed agreed-upon levels of performance
- Create a positive, performance-based culture within Medical Affairs that is built on trust, and aligns with the overall Intarcia culture
- Monitor and analyze CMS Regulations
Qualifications for medical management
- Bachelor’s degree in Health Care, Business, or 11 – 14 years equivalent working experience
- Administrative experience on a hospital committee, in a medical group or for an insurer preferred
- Communication skills both oral and written, tact and diplomacy sufficient to successfully carry out the above duties and responsibilities
- Unrestricted licensed physician
- Learns and applies approved IT and business project management methods to projects to build expertise in PM
- Learns and adheres to approved IT project management standards and controls
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Medical Management Job Description
Job Description Example
Our company is growing rapidly and is looking to fill the role of medical management. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for medical management
- Identify, select, structure, and prioritize process improvement projects and revises to meet changing needs and requirements
- Follow up with workgroup team members as appropriate
- Lead projects across internal and or external divisions or areas
- Manages utilization program as a result of day-to-day management and successful implementation of initiatives
- Creates a team oriented management environment, enhancing the integration between the clinical and operations sections of medical affairs
- Manages mentors and supports staff in designated department or region
- Reviewing and recommending evidence-based, specialty-specific tools, such as Clinical Evidence Reviews, white papers created by HealthTrust
- Retrieves, reviews, processes, and analyzes demographic, clinical and financial data provided by clients to identify unnecessary clinical and cost variation and solutions (service line specific)
- Prepares and presents final client assessments to respective client and leadership
- Keep apprised of regulatory changes and health plan requirements as they pertain to Medical Management business processes and reporting and communicate to Medical Management on an on-going basis
Qualifications for medical management
- Bachelor’s degree, PMP desirable
- At least five years’ experience in the biotech, device, or pharmaceutical industry, Medical Affairs preferred
- You have successfully supported the launch of transformative products
- You are creative and have a track record of challenging industry practices
- You have shown the ability to thrive in a small but rapidly growing and changing organization
- Basic knowledge of Medicare / Medicaid regulations
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Medical Management Job Description
Job Description Example
Our company is hiring for a medical management. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for medical management
- Monitor and ensure compliance of policies and procedures and data integrity / clean up efforts with respect to use of the application
- Triage authorization related issues to provide appropriate support
- Develop and communicate medical management system updates as needed
- Assist with the rollout and use of data entry system(s) in individual market
- Conduct training on the Medical Management system for all end users, new employees, and refresher courses as needed
- Responsible for the development and maintenance of all training materials and job aids
- Develops, writes, modifies and coordinates training manuals based on need evaluation of the user
- Identifies training needs based on trainer review reports, errors reports and audits
- Monitors trainees via a documentation system to measure progress and to evaluate effectiveness of training
- Coordinate training schedule with the hiring and training demands of the department
Qualifications for medical management
- Current, unrestricted RN license ORlicensed social worker or behavioral health clinician (bachelors or higher level degree)
- Experience with Diabetes population
- Strong understanding of supply chain, hospital and healthcare consumerism (value-based payment models, provider and physician challenges )
- Conducts on-site visits to monitor and access process compliance
- Trains technical staff on Policies and Procedures
- Conducts training as needed on other business applications as it pertains to medical management which includes NAMMNet web application and Crystal report writer
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Medical Management Job Description
Job Description Example
Our company is looking for a medical management. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for medical management
- Analyzes member/population data to guide and manage program direction, ensuring that members enroll in clinical programs indicated by their clinical need
- Handles first party medical benefit claims, including fatalities and self-employed wage loss claims
- Evaluates, processes and takes appropriate action on claim-related bills and medical, rehabilitation and special investigative reports
- Establishes immediate contact with Policyholders and Claimants
- Cross-functionally integrates and manages resources, including budget and headcount, to achieve MAT deliverables
- Collects and communicates performance measures for MAT operation across the portfolio
- Assess portfolio issues and develop solutions to ensure overall portfolio productivity, quality, and timelines are met within budget, involving other functional areas where appropriate
- Provide daily oversight to the staff technicians
- Ensure departmental operational functionality related to clinical claims audit, pending claims, customer service inquiries, provider reconsiderations, transplant coordination and cost savings reporting
- Meet regulatory requirements regarding accurate and timely claims administration related to clinical/claims audit and productivity reporting
Qualifications for medical management
- Detail oriented and excellent interpersonal skills and demonstrated written and verbal communication skills necessary to interact with a diverse patient population, providers and staff
- Experience with medical record keeping
- Possesses proficient PC skills and demonstrate proficient usage of various software to include spreadsheets, databases, , in addition to the ability to use highly specialized/customized software for database management and preparation
- Training and/or presenting experience with excellent communication skills and ability to teach all levels of staff
- Knowledge of current medical management business processes
- Knowledge of regulatory and health plan requirements
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Medical Management Job Description
Job Description Example
Our innovative and growing company is hiring for a medical management. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for medical management
- Provide exceptional leadership to the medical Management Staff
- Oversee medical record review of PIP pre-certification auto injury claims to establish medical necessity and causal relationship
- Engages daily and ongoing with line inpatient review nurses, reviewing cases electronically or in verbal case discussion, (and less often in group discussion) with the goals of achieving the delivery of the right care at the right time in the most appropriate setting
- As a clinical resource and coach, assists nurses in having and improving insight into where and when opportunity exists
- Develops and delivers clinical education programs that address the specific needs of the local team
- Participates in national forums, sharing ideas on best practices with other medical directors and clinical leaders from other UCS sites
- Works in close collaboration with site nursing leadership to provide strong leadership to staff
- As needed, participates in other utilization management activities such as pre-certification review, appeals and grievance adjudication
- Apply health plan review hierarchy to member contracts, medical policy, clinical guidelines and other approved resources to render timely decisions on medical necessity requests
- Perform all types of UM reviews, including but not limited to Pre-service, Post-service, Concurrent Review and Appeals
Qualifications for medical management
- RN License in Pennsylvania required
- Active Massachusetts state medical license
- Medical staff privileges at Saint Vincent Hospital in good standing
- Bachelor's degree from an accredited college or university in an engineering, scientific, or technical discipline
- Four (4) years of technical experience in research, development, and/or acquisition activities related to of the following
- DoD TOP SECRET security clearance or higher