Medical Drug Management Operations Specialist
- (2400551)

Note, this is a remote opportunity . Eastern Time Zones preferred.

Collaborates with providers and across internal departments to ensure the safe, timely, appropriate, and necessary covered medical drugs and associated services/procedures for members. Works to reduce provider appeals and drives operational efficiencies for health systems and internally, ultimately improving the provider and member experience. Serves as an operational subject matter expert, both internally and to providers on Medical Drug Management (MDM). Provides operational information to Contracting and Claims areas to support strong provider relationships.
Responsibilities

• Serves as the operational expert on non-clinical vendor and program oversight requirements of the MDM program. Investigates MDM concerns identified by Pharmacy management, Medical Directors, Provider Contracting, Actuarial, Finance, etc., to ensure claims are being paid correctly and to determine what is driving the medical drug trend. Validates accuracy of MDM reports for internal stakeholders and employer groups. Updates MDM drugs list and sends to vendor and internal departments for claims system and outpatient drug routing table.

• Manages inquiries from internal and external partners. Researches, determines resolution, and responds directly on non-clinical inquiries or routes to Clinical professionals for clinical inquiries. Assists MDM vendor with processing of rejected claims from claims system. Research and coordinates with other areas, as needed, to resolve complex claims and investigate claim payment issues.

• Analyzes data, identifies issues, assesses root cause, where applicable recommends interventions including process and/or system changes. Keeps management informed of key customer experience issues as well as any concerns that could impact other areas.

• Acts as main contact for providers and health systems for MDM issues and attends Joint Operating Committee meetings.

• Keeps up to date with best practices, changes in regulations and internal policies and procedures to proactively address/avoid potential issues. Builds and maintains knowledge by participating in recommended training and seminars.

• Performs other duties as assigned.

Qualifications
Education and Experience

• Bachelor’s Degree in Business or Healthcare Administration, Marketing or related field preferred, but will consider collective experience, training and education.

• 5 years progressive support experience in health insurance provider relations, provider contracting, or account management or equivalent experience in claims and/or customer service.

Technical Skills and Knowledge

• Knowledge of provider payer processes and HIPAA and Electronic Data Interchange (EDI) compliance.

• Knowledge of claims adjudication, contract interpretation and/or benefit administration.

• Strong customer service/provider relations skills.

• Intermediate Microsoft Office, web portal and claims systems skills.

Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees. That's why we offer an exceptional package that includes:
A Great Place to Work:

• We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
• Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available. Enjoy the use of weights, cardio machines, locker rooms, classes and more.
• On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
• Discounts at many places in and around town, just for being a Medical Mutual team member.
• The opportunity to earn cash rewards for shopping with our customers.
• Business casual attire, including jeans.

Excellent Benefits and Compensation:

• Employee bonus program.
• 401(k) with company match up to 4% and an additional company contribution.
• Health Savings Account with a company matching contribution.
• Excellent medical, dental, vision, life and disability insurance — insurance is what we do best, and we make affordable coverage for our team a priority.
• Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work/life benefits.
• Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
• After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.

An Investment in You:

• Career development programs and classes.
• Mentoring and coaching to help you advance in your career.
• Tuition reimbursement up to $5,250 per year, the IRS maximum.
• Diverse, inclusive and welcoming culture with Business Resource Groups.

About Medical Mutual:
Medical Mutual’s status as a mutual company means we are owned by our policyholders, not stockholders, so we don’t answer to Wall Street analysts or pay dividends to investors. Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.
There’s a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans. Our plans provide peace of mind to more than 1.2 million Ohioans.
We’re not just one of the largest health insurance companies based in Ohio, we’re also the longest running. Founded in 1934, we’re proud of our rich history with the communities where we live and work.
At Medical Mutual and its family of companies we celebrate differences and are mutually invested in our employees and our community. We are proud to be an Equal Employment Opportunity and Affirmative Action Employer. Qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, veteran status, or disability status.
We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.

Primary Location United States

Job 7 - General Staff

Organization Pharmacy

Schedule Regular

Shift Standard

Employee Status Individual Contributor

Job Type Full-time

Job Level Day Job

Job Posting Nov 14, 2024, 10:02:39 AM