Population Health Specialist II

Network Health; Menasha, Midway Place (WI, LA); Remote; USD 50,000 - 70,000; Full time

Job summary

A leading health organization is seeking a Population Health Specialist II to process authorization requests, support case management, and ensure compliance with regulatory standards. This role involves interaction with members and providers, operational support across departments, and mentoring new employees. The position allows for remote work from Wisconsin with occasional travel required.

Qualifications

• 2 years of healthcare experience in a clinical or insurance setting required.
• Intermediate Microsoft Office skills.

Responsibilities

• Process authorization requests and triage workflow.
• Interact with members and providers regarding authorizations.
• Support other non-clinical projects and tasks as assigned.

Skills

Healthcare Experience

Microsoft Office

Communication

Education

High School Diploma

Job description

Job Title: Population Health Specialist II

The Population Health Specialist II processes Network Health authorization requests in accordance with established guidelines and triages authorization workflow. This role assists with Case Management assignment of candidates and operational support, and with supporting and monitoring compliance with CMS/federal regulatory and NCQA standards related to the authorization process. It provides operational support across various departments including Case, Condition Management, Quality, Wellness, Pharmacy, Government Relations, and Utilization Management, such as requesting and extracting medical records and provider outreach for HEDIS, Health Risk Assessments, Primary Care Provider Attributions, and CIOX medical records. The Specialist may also conduct outbound member calls, including welcome calls and service recovery opportunities.

Job Responsibilities:

1. Demonstrate commitment and behavior aligned with the philosophy, mission, values, and vision of Network Health.
2. Apply all organizational, regulatory, and credentialing principles, procedures, requirements, regulations, and policies appropriately.
3. Enter authorization/pre-determination requests into the information system according to Network Health policies and procedures. Requests include those listed on the NHP/NHIC/NHAS list of services requiring prior authorization.
4. Assign case and condition candidates received via referrals/triggers to appropriate Care or Condition Management Coordinators.
5. Interact with members, practitioners/providers, or other entities via telephone, fax, email, or letter regarding authorizations, case management, claims, and benefit inquiries.
6. Collect member or provider-specific information telephonically or electronically as requested.
7. Assist in mentoring new employees as needed.
8. Support other non-clinical projects and tasks as assigned.
9. Perform other duties as assigned.

Job Requirements:

1. High School Diploma.
2. Two (2) years of healthcare experience in a clinical or insurance setting required.
3. Intermediate Microsoft Office skills.
4. Proficient computer, phone, and faxing skills.

This position is eligible for remote work from your home office in Wisconsin. Occasional travel to the corporate office in Menasha, WI, may be required.

We are proud to be an Equal Opportunity Employer that values diversity and is committed to an inclusive environment.

Equal Opportunity Employer
This employer is required to notify all applicants of their rights under federal employment laws. For more information, review the Know Your Rights notice from the Department of Labor.