Population Health Specialist II (Remote within WI only)
Company: Network Health WI
Posted on: January 26, 2023
Network Health's success is rooted in its mission to create
healthy and strong Wisconsin communities. It drives the decisions
we make, including the people we choose to join our growing team.
Network Health is seeking a Population Health Specialist II. This
individual processes Network Health authorization requests in
accordance with established guidelines and triage authorization
workflow. Assists with supporting and monitoring compliance with
Federal regulatory and NCQA requirements related to Medicare
Advantage, Fully Insured and Health Insurance Exchange (HIX) case,
condition and utilization management processes. Provides
operational support for the Case Management, Condition Management,
and Utilization Management Departments. Coordinates and performs
department KPI data collection and compliance auditing. This role
may have projects that rely heavy on incoming/outgoing phone
presence based on projects department is asked to complete.
- Enter 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
- Interact with member, practitioner/provider, or other entities
via telephone calls, faxes, emails or letters related to
authorizations, case management, claims and benefit
- Refer member candidates to Care Management Coordinators for
case management and/or condition management screening per case
management policies, procedures and established
- Reassign case management member cases to Case Management
Coordinators (CMC) per Manager, CMC request or according to case
management policies, procedures and established desk
- Assist in supporting and monitoring compliance of Case and
Utilization Management processes with CMS/Federal regulatory and
NCQA standards through auditing and review processes.
- Create, populate, review and monitor audit worksheets for
compliance with case management and authorization processes,
including expedited requests, member requests, termination of
provider services (NOMNC), denials (NDMC) and QIO appeals
- Review completed audits with Manager of Utilization and/or Case
- Collaborate with Manager of Utilization and/or Case Management
in the development of solutions based on audit results.
- Communicate with providers regarding Utilization Management
requirements to ensure provider compliance with CMS/Federal
regulatory and NCQA standards.
- Participate in quarterly and ad hoc inter reviewer reliability
- Support Case, Condition and Utilization Management
- Collect and enter member or provider specific information
telephonically or electronically as requested and document such
into specified informational system.
- Complete claims research as requested.
- Support situational department projects as related to strategic
planning initiatives for Case, Condition and Utilization
- Develop/process member letters/mailings as assigned by Case
- Document minutes for applicable team meetings specific to Case
and Utilization Management.
- Review interdepartmental reports and referrals and assigns to
appropriate Case Management coordinator according to set
- Act as a resource person to operations staff and train staff
- This individual may be required to complete non-clinical
projects as requested to support Population Health teams.
- Other duties as assigned.
- High School Diploma required.
- Two (2) years of health care related experience in a clinical
or insurance setting required.
Network Health is an Affirmative Action & Equal Opportunity
Employer. We encourage applications from all backgrounds,
communities and industries, and are committed to having a team that
is made up of diverse skills, experiences and abilities. We are
committed to equality and diversity within Network Health.
*WARNING: Please beware of phishing scams that promote work-at-home
opportunities and which may also pose as legitimate companies.
Please be advised that Network Health recruiter will never ask you
for a credit card, send you a check, or ask you for any type of
payment as part of consideration for a role with our company. All
of our positions require that you first complete an online
Keywords: Network Health WI, Green Bay , Population Health Specialist II (Remote within WI only), Healthcare , Menasha, Wisconsin
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