Care Management Support Assistant

Humana•Toledo, OH

6d•$39,000 - $49,400•Remote

About The Position

The Care Management Support Assistant contributes to the administration of care management by providing non-clinical support for assessing and evaluating members’ needs. The role guides members and families toward resources that support members’ care and wellbeing. It also performs routine administrative, clerical, operational, customer support, and computational tasks. The assistant reviews inbound referrals and correspondence, screens physician orders and documentation for required medical information, and requests additional information when needed. The role verifies benefits and service eligibility, matches referral data to medical terms and codes, and follows established procedures to approve requests or send them for further review. It educates members and providers about medical benefits, referral status, and prior authorizations; confirms patient demographics and explains requested services; and coordinates timely care delivery with providers. The position communicates referral determinations to referring entities, providers, and members, and maintains detailed records of relevant interactions. It works with Pre-Authorization, Utilization Management, Billing, Pharmacy, and Home Care teams. The assistant maintains knowledge of applicable codes, insurance contracts, Medicare/Medicaid criteria, and Health Plan policies, and follows applicable regulations and confidentiality requirements, including HIPAA. The role reports issues that delay service delivery and provides internal and external customer service that meets quality standards. The position is remote, with a scheduled shift of 11:00 a.m. to 7:30 p.m. and rotational weekends. Overtime may be needed. The schedule is 40 hours per week. The position is subject to Florida Level 2 background screening for candidates applying from a Florida work location, including a Florida home-based work location.

Requirements

1–3 years of Home Health or Infusion Pharmacy experience.
Knowledge of Medicare/Medicaid and commercial insurance.
Experience with medical authorizations.
Excellent customer service and communication skills.
Passion for contributing to an organization focused on continuously improving consumer experiences.

Nice To Haves

Wound care/Ostomy supplies experience.
Microsoft Office experience with Word, Outlook, and Excel.
Knowledge of medical billing.

Responsibilities

Review inbound referrals and correspondence for processing, fulfillment, or resolution using appropriate software systems and resources.
Screen physician orders and documentation to ensure required medical documentation and information are included; request additional information when needed.
Verify benefits coverage and eligibility for services according to Health Plan contracts.
Match referral data against medical terms, diagnoses, or procedure codes, then follow procedures to approve requests or refer them for further review.
Educate members and providers about medical benefits, referral status, and prior authorizations.
Contact patients to confirm demographics and explain requested services or care.
Coordinate timely delivery of care and services with providers.
Communicate final referral determinations to referring entities, providers, and members, and document patient, physician, referral source, provider, and communication details.
Work with Pre-Authorization, Utilization Management, Billing, Pharmacy, and Home Care regarding referred services.
Maintain working knowledge of applicable CPT, HCPC, and ICD-10 codes, insurance contracts, Medicare/Medicaid criteria, and Health Plan policies.
Follow applicable federal and state regulations and laws concerning patient confidentiality and release of information, including HIPAA; protect personal information.
Report issues with referring entities or providers that delay service delivery to the manager.
Provide internal and external customer service and ensure work meets quality standards.