The Medical Management Representative supports clinical team and serves as a proactive resource for members related to case management and utilization management.


Duties and responsibilities

  • Conducts educational telephone calls advising members of available benefits, services and programs; refers members to population health management programs as appropriate
  • Reaches out to members with identified gaps in care to provide assistance in securing provider(s) and arranging appointment(s)
  • Manages system work queues; screening identified members for eligibility, prior case activities, recent claims, customer service inquiries and authorization history; assigning members to clinical team for call outreach and intervention
  • Facilitates research and analysis of inquiries and/or complaints and other program related inquiries
  • Functions as a liaison to clinical staff
  • Collects and enters data as appropriate to process prior authorization requests
  • Participates in projects as needed
  • Performs duties such as, but not limited to, project research, data entry, and file management
  • Works with internal and external persons and/or entities to ensure requests, problems and questions are researched and resolved in a timely manner
  • Works overtime as needed
  • Regular and predictable attendance
  • Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice
  • Maintains work area in a clean and orderly condition and ensures safe operating conditions within area of responsibility
  • Works to encourage and promote Company culture throughout the organization
  • Other duties as may be assigned


  • High School diploma or its equivalent
  • Experience in a customer service role is preferred
  • Proficient in Microsoft Office (Outlook, Word, Excel)
  • Working knowledge of NCQA preferred
  • Must be able to work in an independent and creative manner
  • Ability to manage multiple projects and priorities
  • Adaptive to high pace and changing environment
  • Proficient in interpreting benefits and contract language
  • Knowledge of medical terminology


Ethics – Honest, accountable, maintains confidentiality.

Reliability – The extent to which the employee can be depended upon to be available for work, do it properly, and complete it on time. The degree to which the employee is reliable, trustworthy, and persistent.

Sense of Urgency – Meets deadlines, establishes appropriate priority, gets the job done in a timely manner.

Customer Service – Works will with customers, promotes a positive image of the company, strives to solve issues raised by customers.

Communication skills – Possesses effective communication skills: oral, written, listening.

Computer Skills – Skilled with computers, takes advantage of new technology, learns new tools quickly, uses technology to enhance job performance.

Conflict management – Good listener, committed to finding solution to problems, works well with difficult people.

Cooperation – Willingness to work harmoniously with others in getting a job done. Readiness to respond positively to instructions and materials.

Initiative– Takes action, seeks new opportunities, strives to see projects to completion

Job knowledge – Knowledge of products, policies and procedures; OR knowledge of techniques, skills, equipment, procedures, and materials

Physical, Mental, Environmental & Working Conditions

Moderate amount of walking, sitting, and writing. Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day events in the execution of job duties. Needs flexibility and adaptability to change. Candidate must be self-disciplined and a self-starter and able to work independently with a flexible work schedule. Must be able to drive a vehicle and daytime/overnight travel as required.




To Apply: https://www.jobg8.com/ATSApply.aspx?wgEESL%2b1n1tnghkdhjFvpwj