Remote RN – Claims Medical Management Coordinator
- Clinical License RN
- State(s) Nationwide
Full Job Description
Join a passionate and purpose-driven team of colleagues who contribute to Trustmark’s mission of helping people increase wellbeing through better health and greater financial security. At Trustmark, you’ll work collaboratively to transform lives and help people, communities and businesses thrive. Flourish in a culture where appreciation, mutual respect and trust are constants, not just for our customers but also for ourselves.
Position Overview: Our Healthcare Management team is growing and currently looking for a Claims Medical Management Coordinator (CMMC). In this role, you will conduct medical necessity reviews utilizing evidence-based medical criteria, conduct review of medical documentation and provide large claim notifications, identify cases that may benefit from HCM’s case management services, and analyze medical utilization trends to identify probability of future expenditures.
The CMMC works collaboratively to provide clinical support to the HCM Utilization Management department, Trustmark Claims and Underwriting operations, and Stop Loss carriers. To be successful in this role, you must be able to work independently, be an effective communicator, and work collaboratively with internal and external customers through a telephonic and written approach.
This position can be entirely virtual/remote/work from home and the individual can sit anywhere in the US.
- Performs claims medical review determinations utilizing evidence-based medical criteria and guidelines for services that do not require precertification by the group health plan.
- Provides support to the HCM Utilization Management team by performing precertification medical reviews utilizing evidence-based medical criteria and guidelines.
- Refers cases to Trustmark Medical Director or Independent Review Organization (IRO) when it does not meet applicable medical criteria.
- Collaborates with HCM Case Management and identifies members that would benefit from intervention and guidance of the case managers.
- Provides internal and external support to Underwriting and reinsurance carriers by analyzing medical utilization trends, notifying of large dollar claimants, and providing transplant notifications and updates.
- Completes reinsurance grids for Underwriting by providing clinical information and risk of ongoing costs for patients that have reached or exceeded 50% of the carriers’ specific deductibles.
- Bachelor of Science in Nursing preferred, active RN License required
- 3+ years of experience in a clinical setting
- Possess strong time management and organizational skills
- Ability to work independently and complete tasks in a timely manner, reprioritizing workload to meet customer and business needs
- Willingness to adjust and adapt to meet the business needs in an atmosphere that sometimes requires rapid change
- Comfort with telephonic and written communications with all levels of leadership within the organization, providers, stop loss carriers and business contacts in an efficient, professional manner
- Excellent customer service, interpersonal, communication and critical thinking skills
- Comfort with using digital applications including digital documentation system and the ability to accurately document digitally while engaging callers or reviewing medical documents
- Proficient in MS Word, Excel and Outlook Active MCG UM/CM Certification or obtain MCG UM/CM Certification within 6 months of hire
- Utilization Management, Case Management, or Claims experience with a TPA or insurer highly preferred
All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, sexual orientation, sexual identity, age, or disability.