Ancillary Services Case Manager - JHP

Jefferson Health Plans • Jefferson Township, PA

90d

About The Position

We are seeking a talented and enthusiastic Ancillary Services Case Manager to join our team! Work under general supervision to assure cost-effective, quality patient care management for DME, homecare, home infusion, hospice at home, shift care, medical day care, transportation, and outpatient rehab services (including waiver programs, occupational therapy, and speech therapy and physical therapy). As the Ancillary Services Case Manager, your daily duties may include: Process/review requests for durable medical equipment (DME), home care, home infusion, hospice at home, transportation, and outpatient rehab services such as occupational therapy, physical therapy, speech therapy shift care, and medical day care. Evaluate and authorize home care, home infusion, hospice at home, DME, transportation, and outpatient rehab requests for proper medical management and cost-effectiveness. Manage authorization requests received via 278 transactions via the provider portal and right fax queue Within the scope of required education and training, provide a clinical review for appropriateness of care. Utilization of InterQual criteria and Health Partners Criteria will be a source of review and standard for prior authorization. Coordinate with discharge planning, UM, and SNU to facilitate timely approval and coordination of services. Provide ongoing case management with a focus on preventing admissions and ER visits. Provide written and oral communication to members and providers for approvals/denial of services. Select and complete with appropriate language letters to providers and members. Track assigned cases for timely reviews/updates and ensure decisions are reflected in case documentation. Identify duplication of services and opportunities for improvement. Function as a liaison between ancillary providers and members Provide telephone service promptly and courteously. Consults with Medical Directors for medical director review and medical necessity determinations. Meet specified timeframes established by regulators (DHS, NCQA, DOH, and CMS). Identify expanded and continuity of care services and track them for the transition of care. Accurately code all services using appropriate ICD-10, CPT, and HCPCS coding systems. Serves as liaison to customer service representatives, grievance & appeals staff, and other internal staff departments. Assists and supports all related processes, including developing policies, procedures, and process improvement efforts as assigned. Participate in on-call program.

Requirements

• 2+ years clinical nursing experience.
• Homecare and outpatient rehab services experience preferred.
• Experience working in managed care environment preferred.
• Experience with Medicare/Medicaid populations a plus.
• Knowledge of medical necessity principles, including clinical criteria.
• Knowledge of InterQual.
• Computer literacy, including familiarity with Windows and Microsoft Office programs.
• Ability to work independently.
• Ability to work efficiently, with excellent time management skills.
• Excellent communication skills both verbal and written.
• Ability to work well with all types of providers/members.
• Ability to maintain professional demeanor and confidentiality.
• Sensitivity to the needs of every individual to be treated with respect and fairness.

Responsibilities

• Process/review requests for durable medical equipment (DME), home care, home infusion, hospice at home, transportation, and outpatient rehab services.
• Evaluate and authorize home care, home infusion, hospice at home, DME, transportation, and outpatient rehab requests for proper medical management and cost-effectiveness.
• Manage authorization requests received via 278 transactions via the provider portal and right fax queue.
• Provide a clinical review for appropriateness of care within the scope of required education and training.
• Utilize InterQual criteria and Health Partners Criteria for prior authorization.
• Coordinate with discharge planning, UM, and SNU to facilitate timely approval and coordination of services.
• Provide ongoing case management with a focus on preventing admissions and ER visits.
• Provide written and oral communication to members and providers for approvals/denial of services.
• Select and complete letters to providers and members with appropriate language.
• Track assigned cases for timely reviews/updates and ensure decisions are reflected in case documentation.
• Identify duplication of services and opportunities for improvement.
• Function as a liaison between ancillary providers and members.
• Provide telephone service promptly and courteously.
• Consult with Medical Directors for medical necessity determinations.
• Meet specified timeframes established by regulators (DHS, NCQA, DOH, and CMS).
• Identify expanded and continuity of care services and track them for the transition of care.
• Accurately code all services using appropriate ICD-10, CPT, and HCPCS coding systems.
• Serve as liaison to customer service representatives, grievance & appeals staff, and other internal staff departments.
• Assist and support all related processes, including developing policies, procedures, and process improvement efforts.
• Participate in on-call program.

Benefits

• Competitive Compensation Packages, including 401(k) Savings Plan with Company Match and Profit Sharing.
• Flextime and Work-at-Home Options.
• Benefits & Wellness Program including generous Time Off.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Bachelor's degree
• Number of Employees: 501-1,000 employees