Population Health Specialist II

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.

Job Responsibilities:

• 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 prior authorization.
• Interact with member, practitioner/provider, or other entities via telephone calls, faxes, emails or letters related to authorizations, case management, claims and benefit inquiries
• Refer member candidates to Care Management Coordinators for case management and/or condition management screening per case management policies, procedures and established guidelines.
• Reassign case management member cases to Case Management Coordinators (CMC) per Manager, CMC request or according to case management policies, procedures and established desk references.
• 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 (DENC).
  • Review completed audits with Manager of Utilization and/or Case Management.
  • 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 audits.
• Support Case, Condition and Utilization Management programs.
  • 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 Management.
  • Develop/process member letters/mailings as assigned by Case Management Coordinators
  • 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 parameters.
• Act as a resource person to operations staff and train staff when appropriate.
• This individual may be required to complete non-clinical projects as requested to support Population Health teams.
• Other duties as assigned.

Job Requirements:

• High School Diploma required.
• Two (2) years of health care related experience in a clinical or insurance setting required.

This position is eligible to work remote out of your home office in the state of Wisconsin, assuming candidate meets the requirements.

Network Health is an affirmative action and equal opportunity employer.

• 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 application.