Clinical Resource Coordinator - Sharp Extended Care - Copley Drive - Full-Time - Day Shift

Sharp HealthCare•San Diego, CA

2d•$28 - $39

About The Position

To review routine and complex requests for skilled nursing care and related services as part of the discharge plan or during skilled nursing care admissions including requests for specialty outpatient care, retrospective claim review, medical equipment, medication issues and acquisition, home health and admissions from home in accordance with Sharp Community Medical Group (SCMG) and Sharp Rees-Stealy (SRS) referral guidelines. To provide, support, and help facilitate care coordination services provided by the Sharp Extended Care Case Manager.

Requirements

Successful completion of Medical Assistant Program or equivalent work experience.
3 Years Working in the managed health care field, preferably HMO or delegated risk medical group/IPA setting.
Excellent organizational, managerial and time management skills, with the ability to multitask.
Excellent analytical, problem solving, and interpersonal skills with all levels of staff.
Proficient in medical terminology, use of ICD-9 / ICD-10, CPT and HCPC coding systems.
Proficient in typing and computer data entry (45 wpm).
Excellent verbal and written communication skills.
Ability to read, speak and hear English clearly.
Ability to work independently in research and decision making with minimal direction from higher levels of staff.

Responsibilities

Review daily census and ensure accuracy on new admissions and updates referrals for current discharges.
Ensures that all required documentation is attached to IDX authorization (ACM referrals, hospital face sheets, MD orders, criteria, etc.).
Process referrals for DME, SNF, home health, and transportation as needed by the CM team and notifies the proper teams regarding authorizations.
Coordinate timely specialty consult requests for SCMG/SRS patients.
Confirm that authorizations are properly entered as requested by the CM/UM for scheduled surgery, interventional radiology, etc.
Manage correspondence to members and PCP, health plans and other service providers.
Generate phone calls to members, physician offices, health plans, and providers to assist in care coordination under the guidance of case managers. Including reviewing patient's needs and condition for skilled nursing placement from home or other healthcare organizations.
Provide clerical support and assistance to the Case Management and SEC Physician team.
Contribute to the continuous improvement initiatives of the SEC program to deliver quality interventions in a timely manner.
Deliver NOMNC's and RUG letters to skilled nursing facilities in accordance with the program's policies and procedures.
Create post hospital appointments (PHN) as requested by the case manager for the SRS patient population.
Confirm discharges from the previous day and ensures that ACM referrals are forwarded to the appropriate medical group and copies are attached to the SNF referral.
Update referrals in IDX with the discharge date and disposition within 24 hours of patient's discharge.
Ensures that all DME referrals, home health visits, PCP or specialty follow up appointments are authorized prior to patients discharge according to the specific medical group practices and policies.
Sets up the appropriate transportation through contracted ambulance service when needed.
Process referrals that may come in from the PCP's office for additional DME (up to one week post patient's discharge).
Apply the principles of SCMG or SRS guidelines and Health Plan benefit guidelines to approve referrals designated at the CRC level.
Knowledgeable in Microsoft Office applications and additional applications directly related to the Inpatient Unit or SNF department.
Proficient use of all available resources to obtain medical records or patient's current status by using Cerner, Touch works, PPH Cerner, IDX, ECIN, etc.
Understand the Division of Financial Responsibility (DOFR) for each health plan and accurately apply the financial risk concepts when processing referrals.
Process referrals for prior authorization
Perform review of all prior authorization referrals. (Responsible for all levels of the referral from generation, approval and acquisition).
Obtain necessary medical information form the skilled nursing facility, hospital or Primary Care Physicians in order to support any prior authorization requests.
Apply specific health plan criteria and/or guidelines to all prior authorization requests.
Identify and refer requests for review by higher level staff (Medical Director, Hospitalist or CM) within department turnaround time (TAT) standards.
Research and assist in the denial process - gather documentation after review by medical director, ensure packet information is complete, assesses and select the appropriate denial reason.
Maintain mandated TAT for denials.
Process and review appeals from the Skilled Nursing Facility along with the assigned Case manager in order to meet the Quality Improvement Organization (QIO) turnaround time frames.
Verify and document eligibility and benefit details.
Update inpatient IDX referrals with correct diagnosis, bed type and disposition.
Generate informational referrals for patients that are accepted to hospice, custodial level of care or transitions according to the assigned medical group guidelines.
Research and interpret all ICD-9, CPT and HCPC coding using appropriate tools.
Coordinate, review and process retrospective claims for skilled nursing services in compliance with the medical group turnaround guidelines.
Investigate and follow-up on all eligibility issues in accordance with the Account Request Research process.
Actively identifies gaps in skills and competencies and participates in seminars/classes to enhance gaps.
Attends and actively participates in department/team process/quality improvement activities.
Attends required training as scheduled by leadership team.