Medical Management Review Analyst I

Job Summary **Hybrid Work Environment - Must reside on Oahu ** Analyze, research and manage authorization requests from private lines of business for medical review by interpreting applicable medical policies, benefit guidelines, regulatory guidelines and department standards related to contractual and accreditation requirements.
Duties and Responsibilities Analyzes, researches, and interprets medical and claims data while processing authorization requests.
This includes: Authorizes requests that clearly meet specified criteria according to department guidelines.
Refers requests to Medical Directors for determination when appropriate following department and regulatory guidelines.
Ensures necessary medical record information, previous review determinations and other member-specific data are sufficient to make determinations.
Requests any missing information according to medical policy and benefit guidelines following department standards and regulatory statutes.
Ensures requests are processed within regulatory timeliness guidelines.
Maintain productivity rate and meet requirements for accuracy and timeliness for Private Business.
Communicates final case determinations in writing and by telephone providing complete and accurate information using appropriate templates per department and regulatory guidelines.
Documents accurately and completely in a timely manner.
Resolves incoming routine inquiries from members and providers received by telephone, correspondence or email.
Ensures quality outcomes by tracking, researching and documenting updated benefit/medical policy information, unit workflows and inquiry resolution as well as participating in quality improvement activities such as inter-rater reliability reviews.
Performs all other miscellaneous responsibilities and duties as assigned or directed.
#LI-Hybrid Exempt or Non-Exempt Non-exempt Minimum Qualifications Associates degree and one year of related work experience or an equivalent combination of education and/or experience.
Effective written and verbal communication skills.
Basic knowledge of Microsoft Office applications.
Including but not limited to Word, Excel, and Outlook.