Medical Management Job Description
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:
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:
Desired experience for medical management includes:
Medical Management Examples
Medical Management Job Description
- 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
- 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
Medical Management Job Description
- 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
- 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
Medical Management Job Description
- 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
- 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
Medical Management Job Description
- 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
- 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
Medical Management Job Description
- 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
- 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