Anticipated End Date: 2026-03-21 Position Title: Medical Management Specialist I Job Description: Medical Management Specialist I Location: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office. The ideal candidate should be located near one of the following PulsePoints: Woodland Hills-CA, Costa Mesa-CA & Walnut Creek-CA. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Schedule: This position will work an 8-hour shift from 8:00 am - 5:00 pm (PST), Monday through Friday. Additional hours, including weekends or holidays, may be required based on operational needs. The Medical Management Specialist I is responsible for providing non-clinical support to the Medical Management and/or Operations areas. How you will make an impact: Primary duties may include, but are not limited to: - Gathers clinical information regarding case and determines appropriate area to refer or assign case (utilization management, case management, QI, Med Review). - Provides information regarding network providers or general program information when requested. - May assist with complex cases. - May act as liaison between Medical Management and/or Operations and internal departments. - Maintains and updates tracking databases. - Prepares reports and documents all actions. - Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information. Minimum Requirements: - Requires a H.S. diploma or equivalent and a minimum of 1 year experience or any combination of education and experience which would provide an equivalent background. Preferred Skills, Capabilities, and Experiences: - Understanding of managed care or Medicaid/Medicare strongly preferred. - Previous telephonic customer service and claims experience is preferred. - Bilingual (English & Spanish) is a plus. - Experience using Microsoft products is preferred. For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills. For candidates working in person or virtually in the below locations, the salary* range for this specific position is $23.81 to $37.25. Location(s): Woodland Hills-CA, Costa Mesa-CA & Walnut Creek-CA. In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws. * The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law. Job Level: Non-Management Non-Exempt Workshift: 1st Shift (United States of America) Job Family: MED > Medical Ops & Support (Non-Licensed) Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health. Who We Are Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. We are a Fortune 25 company with a longstanding history in the healthcare industry, looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. How We Work At Elevance Health, we are creating a culture that is designed to advance our strategy but will also lead to personal and professional growth for our associates. Our values and behaviors are the root of our culture. They are how we achieve our strategy, power our business outcomes and drive our shared success - for our consumers, our associates, our communities and our business. We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Elevance Health operates in a Hybrid Workforce Strategy. Unless specified as primarily virtual by the hiring manager, associates are required to work at an Elevance Health location at least once per week, and potentially several times per week. Specific requirements and expectations for time onsite will be discussed as part of the hiring process. The health of our associates and communities is a top priority for Elevance Health. We require all new candidates in certain patient/member-facing roles to become vaccinated against COVID-19 and Influenza. If you are not vaccinated, your offer will be rescinded unless you provide an acceptable explanation. Elevance Health will also follow all relevant federal, state and local laws. Elevance Health is an Equal Employment Opportunity employer, and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact elevancehealthjobssupport@elevancehealth.com for assistance. Qualified applicants with arrest or conviction records will be considered for employment in accordance with all federal, state, and local laws, including, but not limited to, the Los Angeles County Fair Chance Ordinance and the California Fair Chance Act. Prospective employees required to be screened under Florida law should review the education and awareness resources at HB531 | Florida Agency for Health Care Administration.

Overview Responsible for improving inpatient clinical documentation through concurrent review of the medical record to ensure accurate physician documentation based on clinical evidence and adherence to official ICD-10-CM coding guidelines. Identifies opportunities for documentation enhancement and queries physicians for clarification to support more specific and accurate diagnoses. Collaborates with physicians and coders to ensure documentation accurately reflects the patient’s severity of illness and risk of mortality. Provides ongoing education to all members of the patient care team to promote consistent, high-quality documentation practices. Qualifications Minimum Qualification & Education Requirements Education & Credentials - Graduate of an accredited school of nursing with current RN licensure in the State of Florida, OR - Advanced Medical Practitioner, OR - International Medical Diploma. Experience - Minimum 3 years of recent clinical experience in a hospital setting. - Certified Clinical Documentation Specialist (CCDS) preferred. - Experience in Utilization Management, Case Management, Quality Improvement, or Inpatient Coding preferred. Motor Vehicle Operator Designation Employees in this position may operate vehicles for assigned business purposes as a non-frequent driver. Licensure / Certification / Registration - Registered Nurse (RN) in the State of Florida required, OR - Advanced Medical Practitioner, OR - International Medical Diploma.

Horizon Blue Cross Blue Shield of New Jersey empowers our members to achieve their best health. For over 90 years, we have been New Jersey’s health solutions leader driving innovations that improve health care quality, affordability, and member experience. Our members are our neighbors, our friends, and our families. It is this understanding that drives us to better serve and care for the 3.5 million people who place their trust in us. We pride ourselves on our best-in-class employees and strive to maintain an innovative and inclusive environment that allows them to thrive. When our employees bring their best and succeed, the Company succeeds. About the Role This position is responsible for performing RN duties using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care. Performs duties and types of care management as assigned by management. Serves as mentor/trainer to new RN's and other staff as needed. Subject matter expert for the various projects and committees as needed. What You'll Do - Assesses patient's clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay. - Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided. - Coordinates and assists in implementation of plan for members. - Monitors and coordinates services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate. Coordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome. - Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care. - Monitors patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness. - Advocates for the member/family among various sites to coordinate resource utilization and evaluation of services provided. - Encourages member participation and compliance in the case/disease management program efforts. - Documents accurately and comprehensively based on the standards of practice and current organization policies. - Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care. - Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes. - Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes. - Serves as mentor/trainer to new RN's and other staff as needed. - Acts as subject matter expert for respective area for projects. - May assume leadership type activities in team leads absence. - Represent clinical teams within committee meetings - Present reports required at committee meetings. - Subject matter expert for user acceptance testing for medical management system. Addendum for Horizon Clinical Advocate Roles: - Outreaches to members identified by Horizon as needing Clinical Advocate services. - Applies critical thinking and clinical expertise to maximize outcomes while interacting with members and their families in a fast-paced environment. - Builds trusting relationships with members and their families utilizing Motivational Interviewing techniques. - Becomes knowledgeable in ASO client employer -sponsored benefits to assist members with questions related to medical benefits, claims, care coordination and other complex needs through explaining benefits and providing education and resources in plain language. - Advocates for members consistently throughout their healthcare journey by coordinating with members, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome. - Focuses on whole person approach, by eliminating “homework” or unnecessary burdens on the members, we can provide a more supportive and engaging experience that addresses overall well-being physical, mental, and emotional. - Schedule: 8- or 10-hour workday Monday through Friday varying between 8am and 11pm. What You Bring Education/Experience: - High School Diploma/GED required. - Bachelor degree preferred or relevant experience in lieu of degree. - Requires a minimum of two (2) years clinical experience. - Requires minimum of two (2) years’ experience with health care payer experience. Utilization Management Only(Utilization Inpatient Case Management does NOT apply to RN II role within HCS) : - RN’s are required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards. Requirements may vary based on department’s business needs. Additional licensing, certifications, registrations: - Active Unrestricted NJ RN License or active Compact License Required. Addendum for Horizon Clinical Advocate roles: - CCM certification preferred. Knowledge: - Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Outlook). Should be knowledgeable in the use of intranet and internet applications. - Requires knowledge of hospital structures and payment systems. - Requires working knowledge of case/care/disease management principles. - Requires working knowledge of operations of utilization, case and/or disease management processes. - Requires knowledge of health care contracts and benefit eligibility requirements. - Requires mentoring knowledge on the operations of utilization/case/disease management. Addendum for Horizon Clinical Advocate roles: - Requires ability to be an empathetic critical thinker. - Requires excellent communication and organizational skills and a high tolerance for ambiguity. - Ability to understand and communicate members benefits, claims and coordination focusing on advocacy principals and effective utilization. - Experience in active listening and motivational interviewing strongly preferred. - Requires a candidate that can work in a collaborative team environment and is a team player who possesses strong analytical, critical thinking and interpersonal skills. - Requires exceptional multi-channel Communication and Interpersonal skills, including the ability to explain complex concepts clearly with compassion. Skills and Abilities: - Adaptability/Flexibility - Analytical - Compassion - Interpersonal & Client Relationship Skills - Information/Knowledge Sharing - Judgment - Listening - Planning/Priority Setting - Problem Solving - Team Player - Time Management - Written/Oral Communication & Organizational Skills Why Horizon? At Horizon, you’ll do meaningful work that directly improves lives—while being supported by a mission‑driven organization that values expertise, collaboration, and growth. We believe that when our people thrive, our communities do too. If you are passionate about making an impact, we’d love to hear from you! Salary Range: $79,100 - $105,945 ​This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions, including but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. This range has been created in good faith based on information known to Horizon at the time of posting. Compensation decisions are dependent on the circumstances of each case. Horizon also provides a comprehensive compensation and benefits package which includes: - Comprehensive health benefits (Medical/Dental/Vision) - Retirement Plans - Generous PTO - Incentive Plans - Wellness Programs - Paid Volunteer Time Off - Tuition Reimbursement Disclaimer: Horizon BCBSNJ employees must live in New Jersey, New York, Pennsylvania, Connecticut or Delaware. This job summary has been designed to indicate the general nature and level of work performed by colleagues within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of colleagues assigned to this job. Horizon Blue Cross Blue Shield of New Jersey is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or status as an individual with a disability and any other protected class as required by federal, state or local law. Horizon will consider reasonable accommodation requests as part of the recruiting and hiring process.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description The Professional Review Analyst analyzes medical services and billing across various claim types to evaluate the accuracy of charges and the medical necessity of care provided. This is a remote role. Candidate must be located in the greater Charlotte, North Carolina Region and able to attend in office training for a minimum of 1 week at start of employment. Essential Functions & Responsibilities: - Identify the necessity of the review process and communicate any specific issues of concern to the claims examiner/client and or direct reporting manager. - Collect supporting data and analyze information to make decisions regarding appropriateness of billing, delivery of care and treatment plans. - Appropriately document work and final conclusions in designated computer program. - Additional duties as assigned. Qualifications - Thorough knowledge of ICD Diagnoses and Procedure Codes, and C.P.T., as well as an understanding of medical terminology. - Knowledge of applicable fee schedule and or applicable U&C Guidelines. - Proficient in Microsoft Office applications. - Technical aptitude with the ability to expand knowledge of MedCheck’s proprietary systems. - Ability to work independently, follow process guidelines, and meet productivity standards and timelines (must maintain a score of 98% or higher on performance audits). Requirements - Associate’s degree or equivalent experience. - CPC or CPC-A required. - Previous experience in the following areas preferred: - Medical bill auditing. - Knowledge of workers' compensation claims process. - Prospective, concurrent and retrospective utilization review. Benefits - CorVel uses a market based approach to pay and our salary ranges may vary depending on your location. - Pay Range: $19.24 - $31.04 per hour. - A comprehensive benefits package is available for full-time regular employees and includes: - Medical (HDHP) w/Pharmacy. - Dental. - Vision. - Long Term Disability. - Health Savings Account. - Flexible Spending Account Options. - Life Insurance. - Accident Insurance. - Critical Illness Insurance. - Pre-paid Legal Insurance. - Parking and Transit FSA accounts. - 401K, ROTH 401K. - Paid time off.