Case Management Representative

Houston Methodist•Sugar Land, TX

About The Position

Serves as a department resource for questions related to case management activities. Communicates in an active, positive, and effective manner to all interprofessional health care team members. Reports pertinent patient care and family data in a comprehensive and unbiased manner. Performs phone call and communication triage, troubleshoots and routes issues to appropriate individuals, assists in resolution of non-clinical issues as needed Facilitates and arranges acquisition of post-acute needs, as directed, and in collaboration with the clinical team. Follows payor/reimbursement practices and regulations that may impact the patient’s plan of care Provides appropriate and timely communication, update, and documentation to the referring personnel to keep them informed of the status of the request Contributes towards improvement of department scores for employee engagement, i.e. peer-to-peer accountability. Assists the department in distributing required notices, including the Medicare Notice of Discharge to patients, securing signatures on the form from the patient or their legal representative, and answering questions regarding the appeal process Distributes the Medicare Notice of Discharges to identified patients, including capturing patient and their legal representative’s signatures, answering any questions regarding the appeal process Coordinates with the clinical staff to prioritize placement requests. Provides necessary documentation to facilitate post-acute services Assists with clerical and clinical functions for patients, physicians, and staff. Provides administrative support as needed, including scheduling follow-up appointments, and confirming the provision or delivery or post-acute services or equipment Participates in quality improvement initiatives and collects data for use in department performance improvement as directed. Maintains timelines for follow up and prioritization of department projects and tasks Updates and maintains resources, information and database or directories elated to post-acute providers and insurance contacts to facilitate timely communication and coordination as needed Informs social worker/case manager of the patients’ available benefits through insurance/managed care provider. Assists in providing community resources/services to uninsured patients as requested Case Management staff Participates in reimbursement/certification and authorization-related activities as directed. Documents approvals and authorization numbers from payors. Logs communications and provides information to social workers and case managers, business office/patient access, etc. on insurance/managed care benefits Supports and assists with concurrent insurance denials and appeals process, transmission of utilization reviews to insurance companies, coordination of peer discussions as directed by the clinical team. Documents authorization, approvals, and denials Maintains awareness of payor/reimbursement practices and regulations that may impact patient’s plan of care and confers with care coordinators and social workers to prioritize placement requests Seeks opportunities to identify self-development needs and takes appropriate action. Ensures own career discussions occur with appropriate management. Completes and updates the My Development Plan on an on-going basis

Requirements

High School diploma or equivalent education (examples include: GED, verification of homeschool equivalency, partial or full completion of post-secondary education, etc.)
Two years of experience in any of the following: service recovery, insurance verification, working with patient information, having patient contact, and/or general health care coordination responsibilities within a healthcare environment
Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
Some knowledge of community resources
Must be able to operate within a Microsoft Office environment.
Proficiency in MS Outlook and MS Word/Excel, knowledge of Medical Terminology
Excellent telephone, oral and written communication skills, time management and prioritization skills
Able to learn new skills effectively
Ability to work independently while collaborating with other team members and exercise sound judgment in interactions with physicians, payors, and patients and their families
Strong organizational and problem-solving skills

Nice To Haves

Associate degree preferred
Previous experience in hospital setting and/or Case Management

Responsibilities

Serves as a department resource for questions related to case management activities.
Communicates in an active, positive, and effective manner to all interprofessional health care team members.
Reports pertinent patient care and family data in a comprehensive and unbiased manner.
Performs phone call and communication triage, troubleshoots and routes issues to appropriate individuals, assists in resolution of non-clinical issues as needed
Facilitates and arranges acquisition of post-acute needs, as directed, and in collaboration with the clinical team.
Follows payor/reimbursement practices and regulations that may impact the patient’s plan of care
Provides appropriate and timely communication, update, and documentation to the referring personnel to keep them informed of the status of the request
Contributes towards improvement of department scores for employee engagement, i.e. peer-to-peer accountability.
Assists the department in distributing required notices, including the Medicare Notice of Discharge to patients, securing signatures on the form from the patient or their legal representative, and answering questions regarding the appeal process
Distributes the Medicare Notice of Discharges to identified patients, including capturing patient and their legal representative’s signatures, answering any questions regarding the appeal process
Coordinates with the clinical staff to prioritize placement requests.
Provides necessary documentation to facilitate post-acute services
Assists with clerical and clinical functions for patients, physicians, and staff.
Provides administrative support as needed, including scheduling follow-up appointments, and confirming the provision or delivery or post-acute services or equipment
Participates in quality improvement initiatives and collects data for use in department performance improvement as directed.
Maintains timelines for follow up and prioritization of department projects and tasks
Updates and maintains resources, information and database or directories elated to post-acute providers and insurance contacts to facilitate timely communication and coordination as needed
Informs social worker/case manager of the patients’ available benefits through insurance/managed care provider.
Assists in providing community resources/services to uninsured patients as requested Case Management staff
Participates in reimbursement/certification and authorization-related activities as directed.
Documents approvals and authorization numbers from payors.
Logs communications and provides information to social workers and case managers, business office/patient access, etc. on insurance/managed care benefits
Supports and assists with concurrent insurance denials and appeals process, transmission of utilization reviews to insurance companies, coordination of peer discussions as directed by the clinical team.
Documents authorization, approvals, and denials
Maintains awareness of payor/reimbursement practices and regulations that may impact patient’s plan of care and confers with care coordinators and social workers to prioritize placement requests
Seeks opportunities to identify self-development needs and takes appropriate action.
Ensures own career discussions occur with appropriate management.
Completes and updates the My Development Plan on an on-going basis