Medical Management Resolution Specialist

About the role

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 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. Learn more at: https://prominence-health.com/ 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.

Responsibilities

• Monitor daily operations of the Medical Management Department.
• Ensure complete and accurate information is provided on all inquiries.
• Meet deadlines per departmental policy, state/federal requirements, and group health plan documents.
• Perform initial screening (Intake Process): review of service request for completeness of information.
• Collect and transfer non-clinical data.
• Acquire structured clinical data.
• Carry out activities that do not require evaluation or interpretation of clinical information.
• Ensure licensed health professionals are available to non-clinical administrative staff while performing initial screening.

Qualifications

• 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 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 MS Office products (Excel, Word, Access, PowerPoint, Outlook).
• Knowledge of medical claim processing preferred.
• Utilization management experience with various lines of business preferred.
• Excellent written and verbal communication skills.
• Must be a