Case Manager III

Patient Advocate Foundation•Washington, DC

5d•Onsite

About The Position

Patient Advocate Foundation (PAF), a national non-profit, headquartered in Hampton, VA, has been solving insurance and healthcare problems since 1996. Our mission is to actively advocate for patients living with chronic and critical illnesses, resolving the healthcare access and affordability challenges they face through the provision of case management services and financial aid. PAF is seeking an organized, self-starter, who is independent and comfortable: Creating a welcoming and professional first impression by making sure patients feel comfortable and heard. Identifying problems, collecting data, establishing facts, and drawing valid conclusions. Working in a high-volume environment and dealing effectively with rapidly changing priorities. Utilizing a system of tools and IT platforms to support the rapidly changing needs of patients. PAF is currently seeking a Case Manager III to join our team in Hampton, VA. Case Managers actively engage to solve patient’s issues, identifying their root causes, developing a plan of action, and interacting with external stakeholders on their behalf to ensure access to care, workplace protections and preservation of their financial stability.

Requirements

5+ years of relevant experience required.
Comprehensive medical terminology and knowledge required.
Significant, direct experience in one or more of the following areas: Leading and coordinating health insurance appeals for patients who are insured through employer sponsored insurance plans (self-insured and fully funded), Medicare, Medicaid, and Marketplace plans. Reading and interpreting insurance plan language. Assisting with prior authorization. Familiarity with coding and billing and working through denied claims that are a result of coding errors/issues; claim resubmission process. Working knowledge of how to research available clinical trials. Utilization review and discharge planning Experience interacting with all payor types (Medicare, Medicaid, commercial insurance and/or Marketplace
Customer service background essential, with understanding of and commitment to providing a consistently high-level of service to patients and their families.
Possess strong research and problem-solving skills.
Demonstrates a high level of initiative and ability to self-direct to solve financial problems of patients, frequently working collaboratively with external entities.
Excellent organization, time management, conflict resolution and negotiation skills required.
Ability to effectively communicate with callers who may be very emotional, angry, or overwhelmed.
Ability to utilize technology tools and telecommunications equipment required to do the job.
Ability to work in a high-volume environment and deal effectively with rapidly changing priorities.
Ability to work independently, retain flexibility and maintain composure under pressure.
Maintain confidentiality and comply with patient privacy guidelines.

Nice To Haves

Professional background in social work, nursing, healthcare administration, health sciences or relevant field, health insurance utilization review and discharge planning preferred.
LCSW, MSN, BSH, RN, LPN, CPC preferred.
Bilingual Preferred.

Responsibilities

Understanding and interpreting insurance plan language.
Determining root cause of coverage denial and addressing accordingly (i.e., coding and billing issue, lack of necessary documentation, denial that needs appeal, etc.).
Generating and mailing appeal letter and supportive documents
Actively collaborating with providers to assist with prior authorizations.
Mediating with insurance companies, medical providers and/or other 3rd party entities on behalf of patients when necessary to bring resolution to denied claims, network issues or coverage disputes.
Requesting and obtaining medical records, notes, and/or detailed bills as appropriate
Determining appropriate language for letters and preparing responses to appeal.
Creating and sending appropriate communications to patients, including follow up and closure letters, surveys and/or authorization forms, when applicable as well as supplemental educational materials.
Entering and maintaining accurate case related information into the program database throughout the engagement of the case
Actively engage with patients and their families over the phone in a timely and professional manner.
Maintain confidentiality and comply with patient privacy guidelines.