Position Summary

Provides clerical support to the Case Management team.

Job Duties

• Reviews all patients’ charts within 24 hours of admission to assess appropriate level of care and medical necessity via Notice of Admission.
• Communicates medical information to managed care companies upon admission and concurrently throughout patient's stay to assure appropriate reimbursement and prevent denials for service.
• Assists the Case Management Office Coordinator II in conducting a retroactive review for any patient admitted and discharged before a review could be completed and insurance information has been updated.
• In the absence of the Case Management Office Coordinator II, conducts the review of faxes from insurance companies regarding medical necessity denials and any lack of clinical information denials, and notifies the Case Manager for resolution.
• Follows up on any ongoing concurrent review determination from the insurance companies.
• Maintains a thorough knowledge of Medicare, Medicaid, and managed care guidelines and/or protocols for utilization management and discharge planning.
• Utilizes all resources available, including electronic inquiries, to verify eligibility, benefits, approvals, and denials.
• Exercises good judgment towards account resolution and documents all activity on the account in a clear, accurate, and consistent manner utilizing the appropriate online system.
• Receives guidance from the Case Management Office Coordinator II regarding the notification to the Director of Case Management of any potential denials from insurance companies for pre-screening.
• Demonstrates excellent customer service skills when responding to incoming or outgoing calls in a courteous manner, providing clear and appropriate information as needed.
• Adheres to all Hospital Regulations associated with Compliance (including HIPAA, etc.).
• Performs other duties as assigned.

Qualifications and Skills

• Strong interpersonal, communication, and organizational skills.
• Sensitivity to varying cultures and ability to interact with a diverse population.
• Proficient in Microsoft Office.
• Bi-lingual in Spanish preferred.

Education, Experience, and Certification/Licensure Requirements

• H.S. Graduate or equivalent; college degree preferred.
• At least 1 year experience in Case Mangement or a related field.
• No certification requirements for this position.