CASE MANAGEMENT SPECIALIST

Beebe Healthcare•Lewes, DE

About The Position

Why Beebe? Become part of the Beebe team - an inclusive team positioned in a vibrant, coastal community. Enjoy a fulfilling career as you support the health of our patients and a team focused on excellence. Overview The main function of the Case Management Specialist is to provide non-clinical support for the Case Management team. The Case Management Specialist inputs, tracks and trends data, interacts with external managed care organizations, physicians, and billing and case management department staff. The position is also responsible for coordinating audits for regulatory agencies and preparing reports for the UR Committee. The CM Specialist will be responsible for identifying issues and recommending process improvement strategies to optimize reimbursement.

Requirements

Two (2) to five (5) years experience in health related field.
Five (5) years of administrative support experience preferred in a hospital setting.
Knowledge of Microsoft Work, Excel, and Power Point required.
Experience with report writing and data analysis required.
Experience with developing and maintaining databases and working with various software applications required.
AA Degree required.
Clear Communication Skills Both Written And Verbal
Knowledge Of Basic Computer Programs
Able To Keep Confidential Information Regarding Patients, Team Members
Able To Withstand Crisis Situations
Has Skills To Provides Customer Service To Patients, Team Members And Visitors
Experience With Excel, Power Point, Word, Visio, Etc.

Responsibilities

Supports both the UR and Discharge planning teams in order to implement more efficient centralized work processes. Rounding with DCP's regarding patients leaving for home and need for referrals in the Unite Us platform to link/refer patients to community resources (single point of contact for platform) . This will involve meeting with patient and completing standardized platform tool. Completion of Patient New Start Dialysis Set up: This involves downloading standard medical information needed for application and forwarding to dialysis provider, scheduling first treatment, interfacing with onsite Davita rep to troubleshoot issues, maintaining communication with assigned discharge planner as to status and any barriers. Maintenance of communication with outside dialysis facility as to patient d/c and anticipated OP start. Assist with application for DART transport as needed.
Enters, tracks, monitors and reports on denial and appeals as well as completing Medicare One Midnight billing holds to finance. IMM's : Important Message from Medicare. Completion of Choice Forms for Home Health, and place referrals for same in Navihealth System, monitoring status. Livanta Appeals- download required medical record documentation, and send via portal for patient (Medicare) appeals.
Acts as a data analyst for the department and interfaces with IT to report on utilization and discharge planning metrics.
Supports Discharge planning staff by obtaining DME and Skilled Nursing authorizations and other related duties as assigned. Management of stock for DME closet, including paperwork, need for refresh/additional equipment, troubleshooting of issues with provider. Assist DCP with obtaining real time updates on bed availability in local SNF's, acute rehab and other post -acute facilities.
Supports long stay rounds, surge plans and prepares outlier reports for the UR Committee. Assists in preparing committee reports with trends and recommendations for UR and revenue cycle meetings. Using Audit tool, review Discharge Planning documentation and requirements ; prepare report with findings to Director.
Effectively extracts pertinent information from managed care organization (MCO) logs and medical records and assists with preparing appeals in a concise, coherent and efficient manner.
Submits UR continued stay documents to managed care organization under the direction of department lead.
Arranges for peer to peer reviews with managed care physician and / or physician advisor or attending. Submits results of Physician Advisor determinations in systems. Liaison b/w BB Infectious Disease and OP Infusion for insurance authorization ( specialty med inpatients only, & needed for d/c), using standardized process.
Contacts Managed Care Organization to obtain authorizations for admissions and continued stay when not accounted for. Coordinates concurrent appeal process by identifying cases, collaborating with physician advisor, utilization review staff and MCO's in an effort to quickly overturn inappropriate denials by the MCO.
Performs other related duties as assigned.