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.