Care Management Specialist

Description:

Summary

SUMMARY: Assists in Care Management Team of social workers and nurses with functions such as but not limited to provide census reconciliation, administrative support for care coordination and discharge planning activities, working with the payors, accurate and critical information data entry and tracking, and report creation.

DUTIES & ESSENTIAL JOB FUNCTIONS: NOTE : The following are the duties performed by employees in this classification. However, employees may perform other related duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

1. Functions as a key point of contact between clinical case management staff, admissions and payors. Documents all interactions with payors and communicates status with Care Management staff.

2. Coordinates and obtains authorizations for admissions; documents all information in the AHS financial system; works closely with Revenue Cycle to ensure each inpatient encounter is accurate; coordinates all reviews and inquires with the payors.

3. Reconciles census; works with Patient Access and the Care management team to ensure census is correct in the financial and care management systems; prepares paperwork and updates encounter information for admissions, discharges and transfers of patients; prepares census for the Care Management staff.

4. Collaborates with Case Management staff to provide specific clinical information for the purpose of completing initial and concurrent utilization review to ensure certification/approval of in-patient and post discharge services.

5. Per the direction of the Care Management social worker and/or nurse, facilitates, identifies and documents all referrals made to contracted facilities, providers or agencies, makes post discharge appointments for patients and coordinates transportation; expedites discharges by transmitting appropriate documentation to providers for acceptance of patient; documents all interactions with payers and communicates status with appropriate staff.

6. Manages multiple inquiries and presents referral based on location and services provided; appropriate follow up on active or pending inquires.

7. Coordinates with referral sources on bed availability, new product and services; maintains current database of existing and potential referral sources.

8. Communicates status with Care Management staff and arranges for patient transfer; functions as a key point of contact between Care Management staff, admissions and payers.

9. Coordinate and track any communication, e.g. Important Message (IM) letters, Denial Letters, patient choice forms; regularly updates Care Management team.

10. Supports any audits with coordinating medical records with HIM; prepares statements of diagnosis and treatments, and extracts other information required for the completion of forms received from patients' insurance carriers.

11. Perform all other duties as assigned.

MINIMUM QUALIFICATIONS:

Required Education : High School Diploma or G.E.D.

Preferred Education : Bachelor's degree in related field.

Required Experience : Three years in a health care field or one year in Utilization Management at a Medical Group or Health plan experience; electronic Health Record (EHR) and Case Management applications, e.g. Midas or 3M.