Clinical Operations Specialist
The Judge Group Inc.

Job Info

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Location: Independence, MO
Salary: $26.00 USD Hourly - $30.00 USD Hourly
Description:

Judge Healthcare is seeking a Clinical Operations Specialiste for one of our top clients in the Independence, MO area.

Position Details:

Title: Clinical Operations Specialist

Location: Independence, MO 64056

Type of Engagement: Contract 6+ months

Specific Duties:

• Performs routine administrative workflow tasks that support functions of Clinical Operations. Identifies cases for internal and external Clinical programs.
• Uses various communication methods to identify and solicit information from providers and vendors as relevant to clinical and business need.
• Coordinates, reviews and investigates claims to determine the medical necessity and appropriateness of the care
• Determines simple cases that require review by Medical Director, Pharmacist or nurse.
• Interprets medical review results to determine compliance with contract provisions.
• Reports suspicions of compliance, clinical, quality, and regulation concerns
• Identifies cases for care and cost management
• Recommend benefit allowances in alignment with contract liabilities
• Actively engages in communication and response with internal and external customers regarding care management, products, and services
• Directs processing of contractual benefits after investigation is complete
• Escalates complex cases to senior team member.

Requirements/Qualifications:

• Requires two years (60 credit hours) of college or 2 years of healthcare experience.
  
• Experience using InterQual is required.
• Additional years of qualifying work experience may be considered in lieu of formal education.
• Requires intermediate proficiency with technology applications and systems.
• Requires experience using Microsoft office products, i.e., Outlook, Excel, Word, Teams.
• Requires effective written and verbal communication skills.
• Functions as part of the MMD Member Experience team, managing incoming calls and faxes from members and providers
• Preferred experience taking inbound calls and making outbound calls.

Work hours: M-F, 40 hours a week, CST time zone

Please send your updated resume and the job number to Sophia Kranias at SCosciaKranias@judge.com for immediate consideration.

Thank you for your time and I look forward to hearing from and working with you.

Regards,

Sophia Kranias

Healthcare Recruiter

The Judge Group

Phone: 610-784-8213

Contact: scosciakranias@judge.com

This job and many more are available through The Judge Group. Find us on the web at www.judge.com

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