Care Management Representative

Qualifications
High School Diploma or GED (Required)
2 year / Associate Degree in Business or related field (Preferred)

Work Experience
1 - 2 years insurance, utilization review, or medical terminology perferably in a Healthcare organization (Required)
1 - 2 years Proficient with computer applications like Microsoft Word and Excel and just in general use of the computer and typing information, experience with Midas would be a plus & nbsp (Preferred)

Licenses and Certifications
No Certifications are Required or Preferred

Essential Functions
UTILIZATION REVIEW - CARE MANAGEMENT:
Serves as liaison with third party payers.
In the normal course of duties and responsibilities, this position requires access to protected health information (PHI) and electronic protected health information (EPHI).
The PHI and EPHI accessed are limited to only the minimum necessary amount of PHI and EPHI necessary to perform the functions of this job. PHI and EPHI are accessed through various computer applications, contact with the patient, Health Information Services, Case Management, and/or other System departments with whom interaction is necessary.
All activities will be performed in support of the strategy, vision and values of Phoebe Putney Health System.
Verify eligibility, benefits, and network status.
Initiate or secure precertification for all applicable accounts according to third party payer requirements.
Responds to inquiries concerning utilization review and care management activities and operations, and refers complex and / or sensitive inquiries to appropriate person(s).
Communicates clinical information, under the direction of the care manager, to third party payers to maximize reimbursement.
Analyzes all information provided by care managers for completeness prior to sending to third party payers for authorization.
Collaborates with care manager to proactively prevent denials
Promptly notifies the Appeals and Denials Coordinator of any denials, potential denials, or additional information requests from insurance companies.
Delivers, explains, and obtains patient / representative's signature for the Secondary Medicare Important Message as needed.
Ensures the completion of authorization requirements identified through care management reports.
Analyzes all CPT codes provided by coders in relation to authorization to assure correct payment.
Communicates with Registration if additional verification of data is needed to be entered on account.
Verifies that prior authorization and eligibility have been obtained if applicable. If neither task has been completed, then proper action is taken to assure prompt notification of the appropriate payer.
Uses third party system work driver for documentation of authorization.
Analyze/view physician orders to determine the correct status to match services to the admission for authorization.
Monitors pre-cert line and returns calls promptly to payers. Communicates all request for clinical information and pre-cert requirements directly to the Care Manager to prevent payment denials.

DOCUMENTATION:
Documents and submits required information and data in a timely fashion.
Clearly and accurately documents designated processes, policies, products, service offerings, etc.
Ensures that documentation is tailored to expected readers / users.
Uses correct terminology.
Conforms to required style and format.

Additional Duties
Adheres to the hospital and departmental attendance and punctuality guidelines.
Performs all job responsibilities in alignment with the core values, mission and vision of the organization.
Performs other duties as required and completes all job functions as per departmental policies and procedures.
Maintains current knowledge in present areas of responsibility (i.e., self education, attends ongoing educational programs).
Attends staff meetings and completes mandatory in-services and requirements and competency evaluations on time.
Demonstrates competency at all levels in providing care to all patients based on age, sex, weight, and demonstrated needs.

For non-clinical areas, has attended training and demonstrates usage of age- specific customer service skills.
Wears protective clothing and equipment as appropriate.