The Case Management Coordinator provides support to the utilization review process. The coordinator works collaboratively with all team members of Utilization Management, Patient and Provider Services, Claims Department and other Care Coordination Department staff.
In addition, the coordinator assists in identifying, tracking and coordinating services for patients when needed. The position requires strong written and communication skills and the ability to interact with Medical Directors, Providers, CSMNS members, Medical Group and IPA's to ensure the delivery of high quality, cost-effective healthcare and aligned with all state and federal regulations and guidelines.
Duties and Responsibilities :
- Enters data and processes referral authorization requests, to include appropriate coding and quantities.
- Answers incoming calls from Providers, IPAs, Medical Groups and other internal and external calls and assists on the queues as needed.
- Is responsible for the Fax Inbox and appropriately distributes incoming faxes. Ensures that internal compliance security measures are met.
- Verifies member eligibility before processing authorizations.
- Contacts facilities identified by the UM Nurses / Manager / Director / Medical Director to research any issues (. contract, discharges, services provided).
- Identifies non-contracted providers and requests Letter-of-Agreements when requested.
- Requests support documentation from IPAs / Medical Groups as requested by the UM Nurses, Medical Directors or Management.
- Processes Extensions and Denial Letters, when needed.
- Prepares Utilization Review Reports as needed.
- Assists the Case / Care Managers in coordinating and arranging services for members.
- Provides assistance to the Claims Department, when requested.
- Documents all patient specific information in appropriate information systems.
- Assists in verifying health plan benefits and coordinating ambulatory services.
- Reviews hospital admissions information and enter / update inpatient, SNF, home health and DME referrals as needed.
- Prints and distributes daily census.
- Seeks and accepts referrals for target patient populations, . fragile seniors, catastrophic and transplant cases, frequent utilizer of ER and inpatient services, and patients diagnosed with specific diseases (cancer, asthma, COPD, AIDS, .
- Acts as a liaison, captures information and documents all patients referred to the ACM / disease state management programs.
- Assists in coordinating care for specific high risk / high cost patient population, including referrals to community resources, facilitation of medical services, referral to ancillary providers, etc.
Education :
High school diploma / GED required.
Experience :
One (1) year of healthcare experience, a general knowledge of medical terminology and experience with community resources and social supports required.
One (1) year of utilization management or managed care experience preferred.
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