What are the responsibilities and job description for the Population Health Specialist II position at Opportunities?
The Population Health Specialist II processes Network Health authorization requests in accordance with established guidelines and triages authorization workflow. This role assists with Case Management assignment of candidates and operational support, and with supporting and monitoring compliance with CMS/Federal regulatory and NCQA standards related to the authorization processes. This role 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 and service recovery opportunities.
Job Responsibilities:
- 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
Job Requirements:
- High School Diploma
- Two (2) year of health care experience in clinical or insurance setting required.
- Intermediate Microsoft Office skills
- Proficient computer and phone/faxing skills
This position is eligible to work remote out of your home office in the state of Wisconsin. Occasional travel to the corporate office (Menasha, WI) may be required for the role.
We are proud to be an Equal Opportunity Employer who values and maintains an environment that attracts, recruits, engages and retains a diverse workforce.
