Ancillary Services Case Manager, RN - Jefferson Health Plan

Jefferson Health Plans•Jefferson Township, PA

About The Position

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). Work under general supervision of manager and team lead to assure cost-effective, quality patient care management for DME, homecare (acute skilled nursing and therapy services), home infusion, hospice at home, transportation, and Shift care (private duty home health for pediatric medically complex members) Process/review requests for durable medical equipment (DME), home care, home infusion, hospice at home, transportation, and Shift care services Evaluate and authorize home care, home infusion, hospice at home, DME, transportation, and Shift care requests for proper medical management and cost-effectiveness. Manage authorization requests received via the provider portal and 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 within strict DHS deadlines. 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 Job Description 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+ year’s clinical nursing experience.
Current PA State RN

Nice To Haves

Homecare and outpatient rehab services experience preferred.
Experience working in managed care environment preferred.
Experience with Medicare/Medicaid populations a plus.

Responsibilities

Process/review requests for durable medical equipment (DME), home care, home infusion, hospice at home, transportation, and Shift care services
Evaluate and authorize home care, home infusion, hospice at home, DME, transportation, and Shift care requests for proper medical management and cost-effectiveness.
Manage authorization requests received via the provider portal and 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 within strict DHS deadlines.
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

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts.
Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service.
All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

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