Case Manager Behavioral Health

Advocate Health and Hospitals Corporation • Macon, GA

5d • $27 - $40

About The Position

Coordinates the patient’s care throughout their stay. Collaborates with the health care team in evaluating the appropriate use of resources, such as medications, procedures, protocols, and tests. Ensures progress towards departmental improvement goals relative to length of stay (LOS) and cost per case. Identifies need for referral to appropriate discipline. Participates in Care Conferences as requested. Engages in utilization management activities appropriate to the patient’s level of care. Maintains an informed status of reimbursement plans, requirements, and guidelines for hospitalization and alternate level of care services. Communicates status to the health care team. Contacts the attending physician and other health care providers whenever additional information is needed for assessment, care planning, or reimbursement purposes. Obtains insurer’s approval for services by providing the insurer with pertinent medical information. Ensures progress towards departmental goals for denial management. Collaborates with the health care team (nurse, pharmacist, physician, therapist, Physician) in monitoring appropriateness of test/procedures, medications, consultations, and treatment plans. In conjunction with Social Service, handles Hospital Issued Notice of Non-Coverage (HINN). Coordinates insurance approvals and obtains pre-certs for all payer sources. Documents insurance information/authorization numbers in relative software applications. Documents calls and related information on designated forms. Establishes and maintains positive relationships with patients, physicians, allied professionals, and all peers. Supports facility internal and external customer service standards. Participates in training and development activities to enhance own knowledge and skills Reviews all cases to assure admission criteria is met. Communicates to the physician if further documentation is needed by regulatory regulations. Assist with chart audits from outside insurance companies. Writes appeals as needed to insurance companies. Arranges peer to peer reviews with physicians and insurance companies. Reports any known compliance issues to Director and Assistant Director of Coordinated Care and Director of BH Financial Operations/Revenue Cycle Operations.

Requirements

• None
• Bachelor's degree in Business, Education, Counseling, Human Services or related field from an accredited institute
• Minimum of two years’ experience in the care of assigned patient population
• Working knowledge of community resources
• Expert knowledge of ICD, CPT, and HCPCS coding guidelines.
• Expert knowledge of medical terminology, anatomy, and physiology.
• Expert ability to identify coding quality issues/concerns and provide recommendations for improvement.
• Expert ability to analyze trends and data and display them in a statistical reporting format.
• Expert organization and communication (verbal and written) skills.
• Expert ability to effectively train others through oral and/or written methods.
• Expert organization, prioritization, and reading comprehension skills.
• Expert analytical skills, with high attention to detail.
• Expert knowledge of Microsoft Office, video and web conferencing, email, and experience with electronic coding and EHR systems or applications.
• Expert knowledge of care delivery documentation systems and related medical record documents.
• Expert interpersonal communication skills (oral and written) necessary to collaborate with Physicians, other clinicians, and Professional Coding Department team members and leadership.
• Ability to work independently and exercise independent judgment and decision-making.
• Ability to meet deadlines while working in a fast-paced environment.
• Ability to take initiative and work collaboratively with others.
• Ability to meet deadlines while working in a fast-paced environment.
• Strong sense of ethics.
• Experience with remote workforce operations required.

Nice To Haves

• Case Management and Utilization Review certification encouraged
• Master's Degree in related field
• Working knowledge of community resources

Responsibilities

• Coordinates the patient’s care throughout their stay.
• Collaborates with the health care team in evaluating the appropriate use of resources, such as medications, procedures, protocols, and tests.
• Ensures progress towards departmental improvement goals relative to length of stay (LOS) and cost per case.
• Identifies need for referral to appropriate discipline.
• Participates in Care Conferences as requested.
• Engages in utilization management activities appropriate to the patient’s level of care.
• Maintains an informed status of reimbursement plans, requirements, and guidelines for hospitalization and alternate level of care services.
• Communicates status to the health care team.
• Contacts the attending physician and other health care providers whenever additional information is needed for assessment, care planning, or reimbursement purposes.
• Obtains insurer’s approval for services by providing the insurer with pertinent medical information.
• Ensures progress towards departmental goals for denial management.
• Collaborates with the health care team (nurse, pharmacist, physician, therapist, Physician) in monitoring appropriateness of test/procedures, medications, consultations, and treatment plans.
• In conjunction with Social Service, handles Hospital Issued Notice of Non-Coverage (HINN).
• Coordinates insurance approvals and obtains pre-certs for all payer sources.
• Documents insurance information/authorization numbers in relative software applications.
• Documents calls and related information on designated forms.
• Establishes and maintains positive relationships with patients, physicians, allied professionals, and all peers.
• Supports facility internal and external customer service standards.
• Participates in training and development activities to enhance own knowledge and skills
• Reviews all cases to assure admission criteria is met.
• Communicates to the physician if further documentation is needed by regulatory regulations.
• Assist with chart audits from outside insurance companies.
• Writes appeals as needed to insurance companies.
• Arranges peer to peer reviews with physicians and insurance companies.
• Reports any known compliance issues to Director and Assistant Director of Coordinated Care and Director of BH Financial Operations/Revenue Cycle Operations.

Benefits

• Paid Time Off programs
• Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
• Flexible Spending Accounts for eligible health care and dependent care expenses
• Family benefits such as adoption assistance and paid parental leave
• Defined contribution retirement plans with employer match and other financial wellness programs
• Educational Assistance Program

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level