Acute Care, Administrative Skills, Case Management, Clinical Validation, Communication Skills, Database Administration, Denials Management, Documentation, English Language, Establish Priorities, Finance, Health Insurance, Healthcare, Healthcare Administration, Insurance, Leadership, MEDITECH, Managed Care, Medical Billing, Medical Records, Microsoft Excel, Microsoft Office, Multilingual, Organizational Skills, Problem Solving Skills, Quality Control, Quality of Care, Regulations, Request for Information (RFI), Risk, Spanish Language, Time Management
Position Summary: Care Management Representative
Responsibilities:
Under the general supervision of the Director/Manager, the Case Management Coordinator performs a variety of supportive services with the focus on facilitating effective communication and sharing of information between departmental staff and external customers and other department. Customers includes (but not limited to) Access Care, business office, Insurance payors, Insurance Case managers and Medical Directors, Post-Acute care facilities, as well as other internal financial departments and the Revenue Cycle Team. The Case Management Coordinator acts as a facilitator between the payors and case managers. Ensures that case certification, case denials and approvals are appropriately recorded and communicated..
The Must be able to provide the following:
⢠Prepare the daily census reports received from Patient Access Department and insurance worksheets for the appropriate assigned Care Managers.
⢠Update the care managers during the course of the workday regarding any changes in the insurance payors or requests from payors.
⢠Communicate with the Physician of record as well as he Physician Advisor (PA).
⢠Determine priority issues for escalation to the Medical Chairperson, leadership and /or the PA regarding high risk issues.
⢠Provides time sensitive administrative support to the care managers by responding to payorsâ requests for clinical reviews and other related information.
⢠Functions as key point of contact for Care managers, third party payors, Patient Access and Patient accounts.
⢠Notifies care managers and the director of any concurrent denials received for timely and appropriate follow up with the physician of record. Facilitate the Peer to Peer process.
⢠Ensures that adverse outcomes (denials) that are received, are appropriately categorized and entered into the database and are appropriately filed. Copies of denials are distributed to Finance for follow up and appeal.
⢠Performs and maintains databases (MIDAS/MEDITECH/XSOLIS) specific to denials, appeals, authorizations and other payment issues
⢠Maintains ALC Logs and ensures that all Alternate Level of Care (ALC) communication to Patient Billing is completed timely and accurately.
⢠Obtains necessary authorization information for all patient types, including, but not limited to obtaining authorization numbers and certifications for post-partum mothers and their newborns.
⢠Assists with the IPRO/LIVANTA Discharge Appeal process by compiling the documents, ensuring that the appropriate chart documentation is obtained and placed on the chart prior to sending requests to HIM for sending the completed chart to IPRO/ Livanta for review. Follows up with IPRO/Livanta for a response and notifies staff when a response is received from IPRO.
⢠Attend to similar process for Level 2 and other communication received from QIOs and regulatory agencies.
⢠Receives and prioritizes insurance requests for clinicals. Submits completed clinicals as requested by payors.
⢠Reconciles the End of Day reports received from various payors. Notifies the Care managers of any discrepancies or outstanding reviews and maintains them in the files for reference and review.
⢠Respond to managed care requests for information.
⢠Maintain denials database, departmental files and logs for ongoing quality control and references.
⢠Maintain confidentiality of all functions, patient and staff information handled by the department.
⢠Other duties as required.
Requirements
Requirements:
⢠BA/BS Degree required
⢠3+ years of experience in HealthCare office Setting
⢠Must be customer focused with excellent telephone etiquette
⢠Experience working with health Insurances and managed care Payors required.
⢠Working knowledge of managing Clinical Denials
⢠Must be able to problem solve and apply critical thinking skills during all situations
⢠Must be computer literate; experienced with Microsoft office especially Excel.
⢠Have the ability to work with multiple computer programs
⢠Must be highly organized, work within the interdisciplinary team
⢠Bilingual in English and Spanish preferred
Benefits
1199 union benefits